PrepU Questions

Constant bubbling in the water seal of a chest drainage system indicates which problem? Air leak Tidaling Tension pneumothorax Increased drainage

Air leak

Which term is used to describe the inability to breathe easily except in an upright position? Dyspnea Orthopnea Hemoptysis Hypoxemia

Orthopnea

A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects the client has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition? Fresh frozen plasma Normal saline solution Lactated Ringer's solution Packed red blood cells (RBCs)

Packed red blood cells (RBCs)

A nurse is assessing a client with HIV who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority? Oral temperature of 37.2°C (99°F) Tachypnea and restlessness Frequent loose stools Weight loss of 0.45 kg (1 lb) since yesterday

Tachypnea and restlessness

When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to home, the nurse should be sure to include which instruction? "Put on disposable gloves before bathing." "Sterilize all plates and utensils in boiling water." "Avoid sharing such articles as toothbrushes and razors." "Avoid eating foods from serving dishes shared by other family members."

"Avoid sharing such articles as toothbrushes and razors."

A patient has been diagnosed with Cushing's syndrome. The nurse would expect which of the following features to be present upon physical examination? "Buffalo hump" Thin extremities "Moon face" Truncal obesity Purple striae

"Buffalo hump" Thin extremities "Moon face" Truncal obesity Purple striae

A patient experiences a life-threatening hypercalcemic crisis. The provider orders a cytotoxic agent. Which of the following is most likely the drug that is prescribed? Calcitonin Didronel Mithramycin Aredia

Mithramycin

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Administering zolpidem tartrate (Ambien) Assessing laboratory test results as ordered Placing the client in Trendelenburg's position Monitoring the patency of an indwelling urinary catheter

Monitoring the patency of an indwelling urinary catheter

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? Crust around the pin insertion site A small amount of yellow drainage at the left pin insertion site A slight reddening of the skin surrounding the insertion site Pain at the insertion site

A small amount of yellow drainage at the left pin insertion site

A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood? A man who is 81 years of age A woman whose blood pressure is 88/51 mm Hg A man who donated blood 4 months ago A woman who has type 1 diabetes

A woman whose blood pressure is 88/51 mm Hg

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 A low urine specific gravity Electrolyte imbalance Low protein level in the urine Absence of ketones in urine

An elevated hematocrit level Electrolyte imbalance

A nurse is aware of the high incidence of catheter-related bloodstream infections in clients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? Use clean technique and wear a mask during dressing changes. Change the dressing no more than weekly. Apply antibiotic ointment around the site with each dressing change. Irrigate the insertion site with sterile water during each dressing change.

Change the dressing no more than weekly. CVAD dressings are changed every 7 days unless the dressing is damp, bloody, loose, or soiled, in which case they should be changed more often. Sterile technique (not clean technique) is used. Irrigation and antibiotic ointments are not normally used.

A nurse is preparing to palpate a client's thyroid gland. Which action by the nurse is appropriate? Have the client flex his neck onto his chest and cough while she palpates the anterior neck with her fingertips. Place her hands around the client's neck, with the thumbs in the front of the neck, and gently massage the anterior neck. Encircle the client's neck with both hands, have the client slightly extend his neck, and ask him to swallow. Have the client hyperextend his neck and take slow, deep inhalations while she palpates his neck with her fingertips.

Encircle the client's neck with both hands, have the client slightly extend his neck, and ask him to swallow.

A client wants to donate blood before his or her abdominal surgery next week. What should be the nurse's first action? Provide the client with a list of the nearest donation centers. Explain the time frame needed for autologous donation. Remind the client to take supplemental iron before donation. Tell the client that 2 units of blood will be needed.

Explain the time frame needed for autologous donation.

The nurse is developing a plan of care for a patient with peptic ulcer disease. What nursing interventions should be included in the care plan? Select all that apply. Making neurovascular checks every 4 hours Frequently monitoring hemoglobin and hematocrit levels Observing stools and vomitus for color, consistency, and volume Checking the blood pressure and pulse rate every 15 to 20 minutes Inserting an indwelling catheter for incontinence

Frequently monitoring hemoglobin and hematocrit levels Observing stools and vomitus for color, consistency, and volume Checking the blood pressure and pulse rate every 15 to 20 minutes

A patient whose laboratory studies indicates a prolactin level of 200 ng/mL is assessed for a pituitary tumor. During the physical exam, the nurse practitioner notices a number of signs and/or symptoms suggestive of this condition. Which of the following is the most common indicator of a pituitary tumor? Tremors and palpitations Headaches and visual disturbances Galactorrhea Inappropriate responses to stimuli

Galactorrhea

The statements presented here match nursing interventions with nursing diagnoses. Which statements are appropriate for a client who has suffered a head injury? Select all that apply. Ineffective airway clearance: Apply suction as indicated Deficient fluid volume: Administer 1 L of normal saline daily Disturbed sleep pattern: Provide back rubs to the client Ineffective cerebral tissue perfusion: Maintain cerebral perfusion pressure ≤50 mm Hg Interrupted family process: Encourage the family to join a support group

Ineffective airway clearance: Apply suction as indicated Disturbed sleep pattern: Provide back rubs to the client Interrupted family process: Encourage the family to join a support group

A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes? Select all that apply. Infection at school Suboptimal sanitary habits Consumption of sewage-contaminated water or shellfish Sexual activity Ingestion of undercooked beef

Infection at school Suboptimal sanitary habits Consumption of sewage-contaminated water or shellfish Sexual activity

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? Lung function Summer allergies Cardiovascular compromise Insensible fluid loss

Insensible fluid loss

Which assessments should a nurse perform when caring for a client following a cardiac catheterization? Select all that apply. Monitor BP and pulse frequently. Inspect pressure dressing for signs of bleeding. Palpate the pulse in different locations. Inspect the color in every extremity. Palpate the insertion site for tenderness.

Inspect pressure dressing for signs of bleeding. Monitor BP and pulse frequently. Palpate the pulse in different locations.

A nurse is educating a client with coronary artery disease about nitroglycerin administration. The nurse tells the client that nitroglycerin has what actions? Select all that apply. Reduces myocardial oxygen consumption Decreases the urge to use tobacco Dilates blood vessels Decreases ischemia Relieves pain

Reduces myocardial oxygen consumption Dilates blood vessels Decreases ischemia Relieves pain

A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? Hydrostatic pressure Osmosis and osmolality Diffusion Active transport

Osmosis and osmolality

A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube. 1 Sit the client in an upright position 2 Measure the length of the tube that will be inserted 3 Apply gloves to the nurse's hands 4 Tilt the client's nose upward 5 Apply water-soluble lubricant to the tip of the tube 6 Instruct the client to lower the head and swallow

1 Sit the client in an upright position 3 Apply gloves to the nurse's hands 2 Measure the length of the tube that will be inserted 5 Apply water-soluble lubricant to the tip of the tube 4 Tilt the client's nose upward 6 Instruct the client to lower the head and swallow

A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize? Risk for Activity Intolerance Related to the Presence of a Subclavian Catheter Risk for Infection Related to the Presence of a Subclavian Catheter Risk for Functional Urinary Incontinence Related to the Presence of a Subclavian Catheter Risk for Sleep Deprivation Related to the presence of a Subclavian Catheter

Risk for Infection Related to the Presence of a Subclavian Catheter

When teaching about the advantages of autologous blood transfusion to a client, the nurse should include which information? Select all that apply. The primary advantage is prevention of viral infections. It is safer for clients with a history of transfusion reactions. It resolves anemia for clients with a hemoglobin less than 11g/dL. Blood can be transfused to family members and close relatives. If not needed immediately, the blood can be frozen for future use.

The primary advantage is prevention of viral infections. If not needed immediately, the blood can be frozen for future use. It is safer for clients with a history of transfusion reactions.

A client is prescribed postural drainage because secretions are building in the superior segment of the lower lobes. Which is the best position to teach the client to use for postural drainage?

prone with a pillow under hips

A nurse is caring for a client after a thoracotomy for a lung mass. What part of the client's care is the priority for the nurse? Anxiety Gas exchange Impaired mobility Home care

Gas Exchange

The nurse is educating a client who is required to restrict potassium intake. What foods would the nurse suggest the client eliminate that are rich in potassium? Butter Citrus fruits Cooked white rice Salad oils

Citrus fruits

A nurse works in an employee health department of a hospital. She was asked to treat a staff nurse who was exposed to blood from a patient with an HIV infection. The nurse practitioner instituted a PEP protocol that includes which of the following actions? Select all that apply. Start prophylaxis medications between 3 to 6 hours after exposure. Continue HIV medications for 4 weeks postexposure. Practice safe sex for 2 weeks (time for HIV medications to reach a satisfactory blood level). Initiate postexposure testing after 4 weeks. Finish postexposure testing at 6 months.

Continue HIV medications for 4 weeks postexposure. Initiate postexposure testing after 4 weeks. Finish postexposure testing at 6 months.

A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply. Crackles on auscultation Cyanosis Hypertension Shoulder pain Dyspnea Tachycardia

Cyanosis Shoulder pain Dyspnea Tachycardia

Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply. Eating Breathing Ambulating Transferring to a wheelchair Writing

Eating Breathing Transferring to a wheelchair Writing

The nurse is caring for a client who is to receive IV daunorubicin, a chemotherapeutic agent. The nurse starts the infusion and checks the insertion site as per protocol. During the most recent check, the nurse observes that the IV has infiltrated so the nurse stops the infusion. What is the nurse's priority concern with this infiltration? Extravasation of the medication Discomfort to the client Blanching at the site Hypersensitivity reaction to the medication

Extravasation of the medication

The nurse is caring for a client who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown? Verify tube placement. Loop adhesive tape around the tube and connect it securely to the abdomen. Gently rotate the tube. Change the wet-to-dry dressing.

Gently rotate the tube. The nurse verifies the tube's placement and gently rotates the tube once daily to prevent skin breakdown. Verifying tube placement and taping the tube to the abdomen do not prevent skin breakdown. A gastrostomy wound does not have a wet-to-dry dressing.

Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply. Hemiparesis Tachypnea Decreased reactivity of the pupils Bradycardia Hypotension Coma

Hemiparesis Decreased reactivity of the pupils Bradycardia Coma

A client is diagnosed with polycystic kidney disease. Which symptom would the nurse most likely assess? Hypertension Flank pain Fever Periorbital edema

Hypertension

A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding? Vitamin K Octreotide Vasopressin Epinephrine

Octreotide

A client with AIDS is having a recurrence of 10 to 12 loose stools a day. What medication may help this client with controlling the chronic diarrhea? Octreotide Rifaximin Bismuth subsalicylate Atropine diphenoxylate

Octreotide

Which of the following are the immediate complications of spinal cord injury? Respiratory arrest Tetraplegia Spinal shock Paraplegia Autonomic dysreflexia

Respiratory arrest Spinal shock

The nurse confirms placement of a client's nasogastric (NG) tube using a combination of visual and pH assessment of the aspirate. The nurse determines that the NG tube remains properly placed when the pH of the aspirate is alkaline acidic neutral unmeasurable

acidic

The nurse is teaching a client about the functionality of heart muscle. What factor may decrease a client's myocardial contractility? acidosis alkalosis sympathetic activity administration of digoxin

acidosis

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for: chronic obstructive pulmonary disease (COPD). bronchial asthma. acute respiratory distress syndrome (ARDS). renal failure.

acute respiratory distress syndrome (ARDS).

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an: antibiotic. anticoagulant. antihypertensive. anticonvulsant.

anticoagulant

The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds (59 kg) who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer's (LR) × patient's weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post-burn injury?

3422

A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of: Impaired adjustment. Defensive coping. Deficient knowledge (treatment regimen). Health-seeking behaviors (diabetes control).

Deficient knowledge (treatment regimen).

The nurse is caring for a client with chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? Vitamin A Vitamin B12 Vitamin C Vitamin E

Vitamin B12

The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? Select all that apply. Base-bicarbonate deficit Elevated hematocrit level Potassium deficit Sodium deficit Magnesium deficit

Base-bicarbonate deficit Elevated hematocrit level Sodium deficit

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? Checking the client's capillary blood glucose levels regularly Having the client frequently rate his or her hunger on a 10-point scale Measuring the client's heart rhythm at least every 6 hours Monitoring the client's level of consciousness each shift

Checking the client's capillary blood glucose levels regularly

The nurse is administering 2 units of packed RBCs to an older adult patient who has a bleeding duodenal ulcer. The patient begins to experience difficulty breathing and the nurse assesses crackles in the lung bases, jugular vein distention, and an increase in blood pressure. What action by the nurse is necessary if the reaction is severe? (Select all that apply.) Continue the infusion but slow the rate down. Place the patient in an upright position with the feet dependent. Administer diuretics as prescribed. Discontinue the transfusion. Administer oxygen.

Discontinue the transfusion. Administer oxygen. Administer diuretics as prescribed. Place the patient in an upright position with the feet dependent.

The nurse reviews dietary guidelines with a client who had a gastric banding. Which teaching points are included? Select all that apply. Eat six meals a day. Limit meal size to 450 to 500 mL. Do not eat and drink at the same time. Drink plenty of water, from 90 minutes after each meal to 15 minutes before each meal. Avoid fruit drinks and soda.

Do not eat and drink at the same time. Drink plenty of water, from 90 minutes after each meal to 15 minutes before each meal. Avoid fruit drinks and soda.

An ED nurse is assessing a 71-year-old female client for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female clients? Select all that apply. Shortness of breath Chest pain Anxiety Indigestion Nausea

Indigestion Nausea

A nurse is caring for a client with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The client's oxygen saturation is 89% by pulse oximetry. After ensuring the client's immediate safety, what is the nurse's most appropriate action? Perform chest physiotherapy. Reduce the height of the client's bed and remove the NG tube. Liaise with the dietitian to obtain a feeding solution with lower osmolarity. Report possible signs of aspiration pneumonia to the primary provider.

Report possible signs of aspiration pneumonia to the primary provider.

The nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure (gastroduodenostomy). The nurse should address which of the following topics when providing health education? Select all that apply. The procedure carries a risk for dumping syndrome The client is likely to require long-term total parenteral nutrition (TPN) The client's vagus nerve may be altered The client can resume a usual diet in 3 to 5 weeks Part of the client's stomach and colon will be removed

The procedure carries a risk for dumping syndrome The client's vagus nerve may be altered

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." "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." "I will have to monitor my blood glucose level closely and notify the physician if it's constantly elevated." "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates."

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

A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every: 10 g of carbohydrates. 15 g of carbohydrates. 20 g of carbohydrates. 25 g of carbohydrates.

15 g of carbohydrates.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? Ineffective airway clearance related to edema of the respiratory passages Impaired physical mobility related to the disease process Disturbed sleep pattern related to facility environment Risk for infection related to breaks in the skin

Ineffective airway clearance related to edema of the respiratory passages

A client is receiving continuous tube feedings at 75 mL/h. When the nurse checked the residual volume 4 hours ago, it was 250 mL, and now the residual volume is 325 mL. What is the priority action by the nurse? Discard the residual volume. Stop the continuous feeding. Decrease the rate to 40 mL/h. Notify the healthcare provider.

Notify the healthcare provider.

Compliance to a renal diet is a difficult lifestyle change for a patient on hemodialysis. The nurse should reinforce nutritional information. Which of the following teaching points should be included? Select all that apply. Limit protein to 1.6 g/kg/day. Eat foods such as milk, fish, and eggs. Restrict sodium to 2,000 to 3,000 mg daily. Increase potassium to prevent cardiac problems. Restrict fluid to daily urinary output plus 500 to 800 mL.

Eat foods such as milk, fish, and eggs. Restrict sodium to 2,000 to 3,000 mg daily. Restrict fluid to daily urinary output plus 500 to 800 mL.

A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand? Epinephrine Glucagon 50% dextrose Hydrocortisone

Glucagon

A nurse is preparing to perform a dressing change to the site of a client's central venous catheter used for parenteral nutrition. Which equipment and supplies would the nurse need to gather? Select all that apply. Masks Clean gloves Skin antiseptic Alcohol wipes Sterile gauze pads Extension set tubing

Masks Skin antiseptic Alcohol wipes Sterile gauze pads

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia? Cheyne-Stokes respirations Increased urine output Decreased appetite Diaphoresis

Increased urine output

A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority? Fatigue Excess fluid volume Ineffective breathing pattern Imbalanced nutrition: Less than body requirements

Ineffective breathing pattern

The client with chronic renal failure is exhibiting signs of anemia. Which is the best nursing rationale for this symptom? Azotemia Diminished erythropoietin production Impaired immunologic response Electrolyte imbalances

Diminished erythropoietin production

What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply. Hemodilution Increased urinary output Metabolic alkalosis Sodium deficit Hypoglycemia

Hemodilution Increased urinary output Sodium deficit

The nurse is caring for a client who has just returned from the PACU after surgery for peptic ulcer disease. For what potential complications does the nurse know to monitor? Select all that apply. Hemorrhage Inability to clear secretions Perforation Penetration Pyloric obstruction Cachexia

Hemorrhage Perforation Penetration Pyloric obstruction

A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing? Hypercalcemia Hypernatremia Hyperglycemia Hyperkalemia

Hyperkalemia

Which is a complication of hyperthyroidism? Myxedema coma Hypothyroidism Addisonian crisis Acromegaly

Hypothyroidism

Which is a symptom of severe thrombocytopenia? Petechiae Inflammation of the mouth Inflammation of the tongue Dyspnea

Petechiae

A nurse formulates a nursing diagnosis of Impaired physical mobilityfor a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to fat emboli Related to infection Related to femoral artery occlusion Related to circumferential eschar

Related to circumferential eschar

A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge? The client doesn't exhibit rectal tenesmus. The client is free from esophagitis and achalasia. The client reports diminished duodenal inflammation. The client has normal gastric structures.

The client is free from esophagitis and achalasia.

An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following health care provider prescriptions: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? To decrease cerebral arterial pressure To avoid impeding venous outflow To prevent flexion contractures To prevent aspiration of stomach contents

To avoid impeding venous outflow

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? Water-seal chamber Air-leak chamber Collection chamber Suction control chamber

Water-seal chamber

A nurse is reviewing laboratory test results from a client. The report indicates that the client has jaundice. What serum bilirubin level must the client's finding exceed, in mg/dL? Enter the correct number to a single decimal place.

2.0

A nurse is teaching a client about peritoneal dialysis. The nurse should tell the client the dwell time is: 10 minutes 20 minutes 30 minutes 60 minutes

20 minutes

A nurse is working with a client who was diagnosed with HIV several months earlier. This client will be considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what threshold? 75 cells/mm3 of blood 200 cells/mm3 of blood 325 cells/mm3 of blood 450 cells/mm3 of blood

200 cells/mm3 of blood

A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed? furosemide hydrochlorothiazide metolazone spironolactone

furosemide

A nurse is providing education to a client with GERD. The client asks what measures can be taken independently to help reduce the symptoms. Which interventions would the nurse recommend? Select all that apply. maintaining an upright position following meals avoiding foods that intensify symptoms sleeping in a supine position ensuring intake of food and fluids 2 to 3 hours before bedtime

maintaining an upright position following meals avoiding foods that intensify symptoms

A patient has been taught how to perform breast self-examination. After standing in front of a mirror and checking both breasts for anything unusual, which of the following would the patient do next?

place both hands behind her head

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"? "Don't take your insulin or oral antidiabetic agent if you don't eat." "It's okay for your blood glucose to go above 300 mg/dl while you're sick." "Test your blood glucose every 4 hours." "Follow your regular meal plan, even if you're nauseous."

"Test your blood glucose every 4 hours."

Health teaching for a patient with diabetes who is prescribed Humulin N, an intermediate NPH insulin, would include which of the following advice? "Your insulin will begin to act in 15 minutes." "You should expect your insulin to reach its peak effectiveness by 12 noon if you take it at 8:00 AM." "You should take your insulin after you eat breakfast and dinner." "Your insulin will last 8 hours, and you will need to take it three times a day."

"You should take your insulin after you eat breakfast and dinner."

A nurse is responsible for monitoring the diet of a client with hepatic encephalopathy. Which daily protein intake should this 185-pound (84-kilogram) male consume? 16 to 49 grams 50 to 75 grams 76 to 99 grams 100 to 126 grams

100 to 126 grams

A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy? 100 units of regular insulin in normal saline solution 100 units of neutral protamine Hagedorn (NPH) insulin in normal saline solution 100 units of regular insulin in dextrose 5% in water 100 units of NPH insulin in dextrose 5% in water

100 units of regular insulin in normal saline solution

A nurse is caring for a terminally ill client who is receiving chemotherapy and radiation for an aggressive lung cancer. The treatment success is limited in shrinking the tumor, and the treatments are making the client very ill. The client states, "I feel that I would like to stop treatments. I would like to enjoy the time that I have remaining with my family." Which emotional reaction does the nurse recognize that the client is experiencing? Denial Bargaining Anger Acceptance

Acceptance

A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean? No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Can't assess tumor or regional lymph nodes and no evidence of metastasis Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis

Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis

Which of the following is a common complication of an electrical burn injury? Localized edema Absent bowel sounds Loss of mobility Cardiac dysrhythmias

Cardiac dysrhythmias

A client with chest pain arrives in the emergency department and receives nitroglycerin, morphine, oxygen, and aspirin. The health care provider diagnoses acute coronary syndrome. When the client arrives on the unit, vital signs are stable and the client does not report any pain. In addition to the medications already given, which medication does the nurse expect the health care provider to order? Carvedilol Digoxin Furosemide Nitroprusside

Carvedilol

A nurse is caring for a client with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL (408 mmol/L). For what complication is this client at risk? Chronic jaundice Pigment stones in portal circulation Central nervous system damage Hepatomegaly

Central nervous system damage

The physician has prescribed a peripheral IV to be inserted before the client goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter? Choose a hairless site if available. Consider potential effects on the client's mobility when selecting a site. Have the client briefly hold his arm over his head before insertion. Leave the tourniquet on for at least 3 minutes.

Consider potential effects on the client's mobility when selecting a site.

A patient is having diagnostic testing for suspected hyperthyroidism. Which of the following diagnostics correlate with this endocrine disorder? Select all that apply. Decrease in serum thyroid-stimulating hormone (TSH) Increased T3 Increased T4 Increase in radioactive iodine uptake Increases in serum TSH

Decrease in serum thyroid-stimulating hormone (TSH) Increased T3 Increased T4 Increase in radioactive iodine uptake

Post transfusion, the donor stands up immediately after the needle is withdrawn. The nurse should be alert for which vital sign change? Decreased blood pressure. Decreased pulse. Decreased respiratory rate. Elevated temperature.

Decreased blood pressure.

The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level? Bright red venous blood. Elevated temperature. Decreased oxygen level. Increased bruising.

Decreased oxygen level.

As part of HAART therapy, a client is prescribed a non-nucleoside reverse transcriptase inhibitor (NNRTI). What would be an example of a drug from this class? Select all that apply. Abacavir Delavirdine Amprenavir Efavirenz Stavudine

Delavirdine Efavirenz

A client with active schizophrenia has developed acute gastritis after ingesting a strongly alkaline solution during a psychotic episode. Which emergency treatments should the nurse anticipate using with the client? Select all that apply. Diluted lemon juice Diluted vinegar Syrup of ipecac Gastric lavage Aluminum hydroxide

Diluted lemon juice Diluted vinegar Aluminum hydroxide

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 Administration of calcium carbonate Intravenous isotonic saline solution in large quantities Monitoring the patient for fluid overload Administration of a bronchodilator

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

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage of 200mL. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: Notify the physician. Assess pulse and blood pressure. Administer prescribed pain medication. Lay the client's head to a flat position.

Assess pulse and blood pressure.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? Assess the client's level of pain and administer prescribed analgesics. Assess the client's level of anxiety and provide emotional support. Prepare the client for pulmonary artery catheterization. Ensure that the client's family is kept informed of the client's status.

Assess the client's level of pain and administer prescribed analgesics.

An adult client with a history of dyspepsia has been diagnosed with chronic gastritis. The nurse's health education should include what guidelines? Select all that apply. Avoid drinking alcohol Adopt a low-residue diet Avoid nonsteroidal anti-inflammatories Take calcium gluconate as prescribed Prepare for the possibility of surgery

Avoid drinking alcohol Avoid nonsteroidal anti-inflammatories

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? Minimize intake of caffeine, beer, milk, and foods containing peppermint or spearmint Avoid eating or drinking 2 hours before bedtime Elevate the foot of the bed on 6- to 8-inch blocks Eat a low-carbohydrate diet

Avoid eating or drinking 2 hours before bedtime

The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation? Blood gases Complete blood count Blood chemistry Serum alkaline phosphate

Blood gases

Which of the following is the nurse's primary concern when providing end-of-life care for a client and the family? Select all that apply. Maintaining client comfort Arranging plans for after death Supporting family members Providing personal care Completing a head-to-toe assessment Encouraging fluids

Maintaining client comfort Supporting family members Providing personal care

The nurse is aware that hemorrhage is a common complication of peptic ulcer disease. Therefore, assessment for indicators of bleeding is an important nursing responsibility. Which of the following are indicators of bleeding? Select all that apply. Melena Polyuria Bradycardia Tachypnea Thirst Mental confusion

Melena Tachypnea Thirst Mental confusion

After 2-hour onset of acute chest pain, the client is brought to the emergency department for evaluation. Elevation of which diagnostic findings would the nurse identify as suggestive of an acute myocardial infarction at this time? Troponin I Myoglobin WBC (white blood cell) count C-reactive protein

Myoglobin

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? Radiography Myelography Neurologic examination Computed tomography (CT) scan

Neurologic examination

A client is prescribed a histamine (H2)-receptor antagonist. The nurse understands that this might include which medication(s)? Select all that apply. Nizatidithene Ranitidine Famotidine Cimetidine Esomeprazole Lansoprazole

Nizatidithene Ranitidine Famotidine Cimetidine

A client diagnosed with breast cancer has developed neutropenia secondary to chemotherapy. Which of the following would the nurse anticipate as being ordered to address the neutropenia? Select all that apply. Filgrastim Epoetin alfa Pegfilgrastim Ondansetron Paclitaxel

Filgrastim Pegfilgrastim

The adrenal cortex is responsible for producing which substances? Glucocorticoids and androgens Catecholamines and epinephrine Mineralocorticoids and catecholamines Norepinephrine and epinephrine

Glucocorticoids and androgens

A client is suspected of having acromegaly. What definitive diagnostic testing is the most reliable method of confirming acromegaly? A serum glucose level Glucose tolerance test in combination with a GH measurement Growth hormone levels Bone radiographs

Glucose tolerance test in combination with a GH measurement

A client is brought to the emergency department by the paramedics. The client is a type 2 diabetic and is experiencing hyperglycemic hyperosmolar syndrome (HHS). The nurse should identify what components of HHS? Select all that apply. Leukocytosis Glycosuria Dehydration Hypernatremia Hyperglycemia

Glycosuria Dehydration Hypernatremia Hyperglycemia

A clinic nurse is caring for a client admitted with AIDS. The nurse has assessed that the client is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication? HIV encephalopathy B-cell lymphoma Kaposi's sarcoma Wasting syndrome

HIV encephalopathy

A nurse teaches a client with angina pectoris that he or she needs to take up to three sublingual nitroglycerin tablets at 5-minute intervals and immediately notify the health care provider if chest pain doesn't subside within 15 minutes. What symptoms may the client experience after taking the nitroglycerin? Nausea, vomiting, depression, fatigue, and impotence. Sedation, nausea, vomiting, constipation, and respiratory depression. Headache, hypotension, dizziness, and flushing. Flushing, dizziness, headache, and pedal edema.

Headache, hypotension, dizziness, and flushing.

A physician orders laboratory tests to confirm hyperthyroidism in a client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis? No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test A decreased TSH level An increase in the TSH level after 30 minutes during the TSH stimulation test Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay

No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test

Thyroid storm is a severe form of hyperthyroidism that can be fatal if not treated. Medical management includes pharmacotherapy. Which of the following drugs have proved helpful? Select all that apply. Hydrocortisone Acetaminophen Salicylates Methimazole Iodine

Hydrocortisone Acetaminophen Methimazole Iodine

Based on the pathophysiologic changes that occur as renal failure progresses, the nurse identifies the following indicators associated with the disease. Select all that apply. Hyperkalemia Metabolic alkalosis Anemia Hyperalbuminemia Hypocalcemia

Hyperkalemia Anemia Hypocalcemia

When the postcardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects which electrolyte imbalance? Hypokalemia Hyperkalemia Hypermagnesemia Hypomagnesemia

Hypermagnesemia

The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in her lips and fingers. She states that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should the nurse first suspect? Hypophosphatemia Hypocalcemia Hypermagnesemia Hyperkalemia

Hypocalcemia

The nurse is working on a burns unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of what imbalance? Metabolic alkalosis Hypermagnesemia Hypercalcemia Hypovolemia

Hypovolemia

A nurse is caring for a client diagnosed with human immunodeficiency virus (HIV). The client wants to know when medication for the disease will begin. What is the nurse's best response? If the client has a CD4 T-cell count less than 350 cells/mm3. When the client is coinfected with hepatitis C. If the client is diagnosed with HIV-associated liver disease. After the client has been cured of Kaposi's sarcoma.

If the client has a CD4 T-cell count less than 350 cells/mm3.

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis? Incentive spirometry Intermittent positive-pressure breathing (IPPB) Positive end-expiratory pressure (PEEP) Bronchoscopy

Incentive spirometry

Which of the following would the nurse expect to find when reviewing the laboratory test results of a client with renal failure? Increased serum creatinine level Decreased serum potassium level Increased red blood cell count Increased serum calcium level

Increased serum creatinine level

The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance? Suggest a fluid restriction. Encourage oral fluids. Remove the Hemovac. Offer a prescribed antiemetic medication.

Offer a prescribed antiemetic medication.

A medical nurse has admitted a client to the unit with a diagnosis of failure to thrive. The client has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the client's physician because these symptoms are suggestive of what? Pneumothorax Lung tumors Infection Pulmonary edema

Infection

While assessing a client's peripheral IV site, the nurse observes edema around the insertion site. How should the nurse document this complication related to IV therapy? Air emboli Phlebitis Infiltration Fluid overload

Infiltration

A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first? Initiate fluid replacement therapy. Administer insulin. Correct diabetic ketoacidosis. Determine the cause of diabetic ketoacidosis.

Initiate fluid replacement therapy.

A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize what intervention? Lifestyle actions that improve immune function Educational programs that focus on control and prevention Appropriate use of standard precautions Screening programs for youth and young adults

Educational programs that focus on control and prevention

A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells? Filgrastim Sargramostim Epoetin alfa Eltrombopag

Epoetin alfa

Which term refers to the progressive increase in blood glucose from bedtime to morning? Somogyi effect Insulin waning Dawn phenomenon Diabetic ketoacidosis (DKA)

Insulin waning

The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply. Extravasation Infection Hematoma Phlebitis Air embolism

Extravasation Hematoma Phlebitis

During a routine checkup, a nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer? Squamous cell carcinoma Multiple myeloma Leukemia Kaposi's sarcoma

Kaposi's sarcoma

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? Albumin Dextrose 5% in water (D5W) Lactated Ringer's solution Normal saline solution with 20 mEq of potassium per 1,000 ml

Lactated Ringer's solution

A critical care nurse is caring for a client with a pulmonary artery catheter in place. What does this catheter measure that is particularly important in critically ill clients? Pulmonary artery systolic pressure Right ventricular afterload Pulmonary artery pressure Left ventricular preload

Left ventricular preload

The nurse has been asked to teach a patient how to self-administer nitroglycerin. The nurse should instruct the patient to do which of the following? Select all of the teaching points that apply. Put some of the tablets in a small metal or plastic pillbox that can be easily carried at all times and be accessible quickly, when needed. Let the tablet dissolve in the mouth and keep the tongue still. The tablet can be crushed between the teeth but not swallowed. Keep the tablets at home on the kitchen counter or bedside table so they can be reached quickly. Renew the supply every 6 months. Take the tablet in anticipation of any activity that can produce pain. Call emergency services if, after taking three tablets (one every 5 minutes), pain persists.

Let the tablet dissolve in the mouth and keep the tongue still. The tablet can be crushed between the teeth but not swallowed. Renew the supply every 6 months. Take the tablet in anticipation of any activity that can produce pain. Call emergency services if, after taking three tablets (one every 5 minutes), pain persists.

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? Give medications that promote fluid retention. Limit sodium and water intake. Assess for dehydration. Teach client behaviors that decrease urination.

Limit sodium and water intake.

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following? Liver Pancreas Kidney Large intestine

Liver

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? Serum potassium level of 3.5 mEq/L Loss of 2.2 lb (1 kg) in 24 hours Serum sodium level of 135 mEq/L Blood pH of 7.25

Loss of 2.2 lb (1 kg) in 24 hours

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent which condition? Lymphedema Trousseau's sign IV infusion infiltration Muscle atrophy

Lymphedema

In a client who has been burned, which medication should the nurse expect to use to prevent infection? Lindane (Kwell) Diazepam (Valium) Mafenide (Sulfamylon) Meperidine (Demerol)

Mafenide (Sulfamylon)

A nurse is caring for a client who is suspected to have developed a peptic ulcer hemorrhage. Which action would the nurse perform first? Place the client in a recumbent position with the legs elevated. Prepare a peripheral and central line for intravenous infusion. Assess vital signs. Notify the healthcare provider.

Place the client in a recumbent position with the legs elevated.

The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids? Presence of a cough and gag reflex Absence of nausea Ability to demonstrate deep inspiration Oxygen saturation of ≥92%

Presence of a cough and gag reflex

Which of the following is a clinical manifestation of pupillary changes that indicate increasing ICP? Pupils are equal and normally reactive. Pupils are unequal in diameter. Pupils are showing progressive dilation. Pupils are fixed and dilated.

Pupils are showing progressive dilation.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? Dyspnea and fatigue Ascites and orthopnea Purpura and petechiae Gynecomastia and testicular atrophy

Purpura and petechiae

Which term refers to the symptom of gastroesophageal reflux disease (GERD), which is characterized by a burning sensation in the esophagus? Pyrosis Dyspepsia Dysphagia Odynophagia

Pyrosis

Erythropoietin growth factor increases production of which of the following? Red blood cells White blood cells Platelets Plasma

Red blood cells

A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis? White, cottage cheese-like patches on the tongue Yellow tooth discoloration Red, open sores on the oral mucosa Rust-colored sputum

Red, open sores on the oral mucosa

What are the clinical manifestations of gastroesophageal reflux disease (GERD)? Select all that apply. Regurgitation Dyspepsia Pyrosis Hypersalivation Esophagitis

Regurgitation Dyspepsia Pyrosis Hypersalivation Esophagitis

A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention? Respiratory rate of 44 breaths/minute Oxygen saturation level of 96% on 3 L of oxygen Client stating pain level of 7 out of 10 that decreases with pain medication Client dozing when left alone but awakening easily

Respiratory rate of 44 breaths/minute

A nurse reviews a client's laboratory results and notes the client has a decreased lymphocyte count. What nursing diagnosis will the nurse use when planning the client's care? Risk for bleeding Risk for infection Impaired oxygenation Impaired tissue integrity

Risk for infection

A new nursing graduate is working at the hospital in the medical-surgical unit. The preceptor observes the nurse emptying a patient's wound drain without gloves on. What important information should the preceptor share with the new graduate about standard precautions? Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens. Standard precautions should only be used with patients who are HIV positive to reduce the risk of transmission of the HIV virus. It is only necessary to use gloves when you are emptying reservoirs that have body fluids in them. If you are careful and do not expose yourself to blood or body fluids, it is not necessary to use gloves all of the time.

Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens.

Which type of burn is similar to a sunburn? Superficial partial-thickness Electrical Deep partial-thickness Full-thickness

Superficial partial-thickness

A health care provider tells a breast cancer client that he is going to prescribe hormone therapy that has been found to significantly reduce mortality. Which drug would most likely be prescribed? Lapatinib Bevacizumab Tamoxifen Trastuzumab

Tamoxifen

The nurse is teaching the client with HIV about therapy. Which elements are essential for the nurse to include in the teaching plan? Select all that apply. The CD4 count is the major indicator of immune function and guides therapy. Antiretroviral therapy targets different stages of the HIV life cycle. The goal of antiretroviral therapy is to prevent opportunistic infections. Medication therapy is rarely effective. Clients rarely respond to medication therapy.

The CD4 count is the major indicator of immune function and guides therapy. Antiretroviral therapy targets different stages of the HIV life cycle.

A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? The client demonstrates ability to tolerate more activity without chest pain. The client exhibits a heart rate above 100 beats/minute. The client verbalizes the intention of making all necessary lifestyle changes except for stopping smoking. The client states that sublingual nitroglycerin usually relieves his chest pain.

The client demonstrates ability to tolerate more activity without chest pain.

A nurse on the renal unit is caring for a client who will soon begin peritoneal dialysis. The family of the client asks for education about the peritoneal dialysis catheter that has been placed in the client's peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply. The cuffs are made of Dacron polyester. The cuffs stabilize the catheter. The cuffs prevent the dialysate from leaking. The cuffs provide a barrier against microorganisms. The cuffs absorb dialysate

The cuffs are made of Dacron polyester. The cuffs stabilize the catheter. The cuffs prevent the dialysate from leaking. The cuffs provide a barrier against microorganisms.

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? Voice or sip-n-puff controlled electric wheelchair Electric or modified manual wheelchair, needs transfer assistance Cane The patient will be able to ambulate independently.

The patient will be able to ambulate independently.

A client receives tube feedings after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which measure should the nurse include in the care plan to reduce the risk of aspiration? Change the tube feeding container, tubing, and adjust patient head of bed . Avoid cessation of feedings and adjust patient head of bed. Use semi-Fowler position during, and 60 minutes after, an intermittent feeding. Administer 15 to 30 mL of water before and after medications and feedings.

Use semi-Fowler position during, and 60 minutes after, an intermittent feeding.

The client is to receive a unit of packed red blood cells. What is the nurse's first action? Check the label on the unit of blood with another registered nurse. Ensure that the intravenous site has a 20-gauge or larger needle. Observe for gas bubbles in the unit of packed red blood cells. Verify that the client has signed a written consent form.

Verify that the client has signed a written consent form.

What normal change due to aging does the nurse expect in the heart of an older client? Decreased left ventricular ejection time Decreased connective tissue in the SA and AV nodes and bundle branches Thinning and flaccidity of the cardiac values Widening of the aorta

Widening of the aorta

The primary source of microorganisms for catheter-related infections are the skin and the catheter tubing. catheter hub. IV fluid bag. IV tubing.

catheter hub

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? dehydration hypervolemia hypercalcemia hyperkalemia

dehydration

A client is experiencing edema in the tissue. What type of intravenous fluid would the nurse expect to be prescribed? isotonic fluid no intravenous solution hypertonic solution hypotonic solution

hypertonic solution

A client's renal failure has become chronic. Which signs and symptoms are associated with chronic renal failure? Select all that apply. lethargy muscle cramps bleeding of the oral mucous membranes enhanced cognition

lethargy muscle cramps bleeding of the oral mucous membranes

A client diagnosed with acute kidney injury (AKI) has a serum potassium level of 6.5 mEq/L. The nurse anticipates administering: sodium polystyrene sulfonate (Kayexalate) Sorbitol IV dextrose 50% Calcium supplements

sodium polystyrene sulfonate (Kayexalate)

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? "Lie down after meals to promote digestion." "Avoid coffee and alcoholic beverages." "Take antacids with meals." "Limit fluid intake with meals."

"Avoid coffee and alcoholic beverages."

A client verbalizes fear of infection from a blood transfusion. What is the nurse's best response? "The risk of transmission of HIV is so low, there's no need to worry." "Blood typing is more important than testing for infection." "There is no need for testing unless you have a history of a transfusion reaction." "Every unit of donated blood is typed and tested for antibodies to infections."

"Every unit of donated blood is typed and tested for antibodies to infections."

A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, "I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse? "I understand what you mean, you can never be sure if the blood is tainted." "I understand your concern. The blood is screened very carefully for different viruses as well as HIV." "If you don't have the blood transfusions, you may not make it through this episode of bleeding." "No one has gotten HIV from blood in a long time. You have to have the transfusion."

"I understand your concern. The blood is screened very carefully for different viruses as well as HIV."

A 16-year-old has come to the clinic and asks to talk to a nurse. The teen states that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do to keep from getting HIV. What would be the nurse's best response? "There's no way to be sure you won't get HIV except to use condoms correctly." "Only the correct use of a female condom protects against the transmission of HIV." "There are new ways of protecting yourself from HIV that are being discovered every day." "Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV."

"Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV."

A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response? "You could have gotten it by using I.V. drugs." "You must have received an infected blood transfusion." "You probably got it by engaging in unprotected sex." "You may have eaten contaminated restaurant food."

"You may have eaten contaminated restaurant food."

A client who has been exposed to the human immunodeficiency virus (HIV) tests negative. Which explanation by the nurse would be most appropriate? "Congratulations, a negative result means that you're not infected with the virus." "You're one of the lucky ones who are immune to the virus." "You might still go on to develop AIDS even with negative results." "Your body may not have developed antibodies yet, so we need to follow up."

"Your body may not have developed antibodies yet, so we need to follow up."

The nurse is caring for a patient that has developed oliguria. Oliguria is defined as urine output less than ___________mL/kg/hr.

0.5

The palm represents which percentage of a person's TBSA? 1% 5% 10% 15%

1%

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long? 0 to 5 seconds 10 to 15 seconds 30 to 35 seconds 20 to 25 seconds

10 to 15 seconds

A client presents to the emergency department reporting chest pain. Which order should the nurse complete first? 12-lead ECG 2 L oxygen via nasal cannula Troponin level Aspirin 325 mg orally

12-lead ECG

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? A urine output consistently above 40 ml/hour A weight gain of 4 lb (2 kg) in 24 hours Body temperature readings all within normal limits An electrocardiogram (ECG) showing no arrhythmias

A urine output consistently above 40 ml/hour

What pharmacologic therapy does the nurse anticipate administering when the patient is experiencing thyroid storm? (Select all that apply.) Acetaminophen Iodine Propylthiouracil Synthetic levothyroxine Dexamethasone (Decadron)

Acetaminophen Iodine Propylthiouracil

A client has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this client's immediate care? Select all that apply. Administering diuretics to prevent fluid overload Administering beta blockers to reduce heart rate Administering insulin to reduce blood glucose levels Applying interventions to reduce the client's temperature Administering corticosteroids

Administering beta blockers to reduce heart rate Applying interventions to reduce the client's temperature

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? Pain Fluid balance Anxiety and fear Airway management

Airway management

What ECG findings does the nurse observe in a patient who has had a myocardial infarction (MI)? (Select all that apply.) An absent P wave An abnormal Q wave T-wave inversion ST-segment elevation Prolonged P-R interval

An abnormal Q wave ST-segment elevation T-wave inversion

A terminally ill client has feelings of rage toward the nurse. According to Elisabeth Kübler-Ross, the patient is in which stage of dying? Denial Anger Bargaining Depression

Anger

The nurse is caring for a client with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply. Percuss for pain in the right lower abdominal quadrant. Assess for the presence of peripheral edema. Auscultate the client's apical heart rate for dysrhythmias. Assess the client's BP. Assess the client's orientation and judgment.

Assess for the presence of peripheral edema. Assess the client's BP.

A client with a history of chronic renal failure receives hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan? Keep the AV fistula site dry. Keep the AV fistula wrapped in gauze. Take the client's blood pressure in the left arm. Assess the AV fistula for a bruit and thrill.

Assess the AV fistula for a bruit and thrill.

Which type of graft utilizes the client's own skin for wound coverage? Heterograft Allograft Autograft Slit graft

Autograft

The nurse is caring for a client diagnosed with unstable angina who is receiving IV heparin. The client requires bleeding precautions. Bleeding precautions include which measure? Avoid continuous BP monitoring Avoid subcutaneous injections Use an electric toothbrush Avoid the use of nail clippers

Avoid continuous BP monitoring

A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? Elevated serum acetone level Serum ketone bodies Serum alkalosis Below-normal serum potassium level

Below-normal serum potassium level

A nurse is caring for an older adult client who has type 2 diabetes mellitus. The nurse suspects the client is exhibiting symptoms of diabetic ketoacidosis (DKA) instead of hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which indicators support the diagnosis of DKA? Select all that apply. Blood glucose level of 280 mg/dL Arterial pH of 7 Presence of ketones in the urine Serum osmolality of 380 mOsm/L Plasma bicarbonate level of 13 mEq/L

Blood glucose level of 280 mg/dL Arterial pH of 7 Presence of ketones in the urine Plasma bicarbonate level of 13 mEq/L

When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred? C3 C5 T6 L1

C5

A client with acquired immune deficiency syndrome (AIDS) comes to the clinic reporting difficulty swallowing. The client says, "It hurts so much when I swallow." Inspection reveals creamy white patches in the client's mouth. What will the nurse suspect? Candidiasis Wasting syndrome Cryptococcus neoformans Clostridium difficile diarrhea

Candidiasis

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following is cause of a secondary injury associated with brain injury? Select all that apply. Cerebral edema Ischemia Infection Seizures Hyperthermia

Cerebral edema Ischemia Infection Seizures Hyperthermia

Which is a true statement regarding hospice care? Clients have a life expectancy of 6 months or less. It is cure-focused. It encourages the prolongation of life through artificial means. Patients have an acute illness.

Clients have a life expectancy of 6 months or less.

What quick assessment technique should the nurse use to assess the percentage of burn injury? Observe the color of the client's wound Check the client's vital signs Compare the client's palm with the size of the burn wound Observe the client's level of consciousness

Compare the client's palm with the size of the burn wound

A client is admitted for treatment of Prinzmetal's angina. When developing this client's care plan, the nurse should keep in mind that this type of angina is a result of what trigger? Activities that increase myocardial oxygen demand. An unpredictable amount of activity. Coronary artery spasm. The same type of activity that caused previous angina episodes.

Coronary artery spasm.

The nurse is reviewing the laboratory results for a patient having a suspected myocardial infarction (MI). What cardiac-specific isoenzyme does the nurse observe for myocardial cell damage? Alkaline phosphatase Creatine kinase MB Myoglobin Troponin

Creatine kinase MB

A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus? Hyperactive bowel sounds Decreased peristalsis Fecal occult blood Hematemesis

Decreased peristalsis

During hemodialysis, toxins and wastes in the blood are removed by which of the following? Diffusion Osmosis Ultrafiltration Filtration

Diffusion

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 Accelerated behaviors and mental processes Hemorrhoids Excess storage of vitamin C

Enlarged liver size Ascites Hemorrhoids

A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation? Epidural hematoma Acute subdural hematoma Chronic subdural hematoma Grade 1 concussion

Epidural hematoma

Which of the following would the nurse most likely assess in a client with diabetes who is experiencing autonomic neuropathy? Skeletal deformities Paresthesias Erectile dysfunction Soft tissue ulceration

Erectile dysfunction

A client is being treated for AKI and the client daily weights have been ordered. The nurse notes a weight gain of 3 pounds (1.4 kg) over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? Imbalanced Nutrition: More than body requirements Excess Fluid Volume Sedentary Lifestyle Adult Failure to Thrive

Excess Fluid Volume

Nursing students are reviewing various procedures that can be used to obtain a tissue biopsy of the breast. They demonstrate understanding of the material when they identify which of the following as being done using local anesthesia and intravenous (IV) sedation? Select all that apply. Fine-needle aspiration Excisional biopsy Stereotactic biopsy Wire needle localization Core needle biopsy

Excisional biopsy Wire needle localization

A sputum study has been ordered for a client who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample? Immediately after a meal First thing in the morning At bedtime After a period of exercise

First thing in the morning

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position? Flat Supine, with the head of the bed elevated 30 degrees Flat, except for logrolling as needed A head elevation of 90 degrees to prevent cerebral swelling

Flat, except for logrolling as needed

Skin grafts are necessary for which of the following burns? Superficial Superficial partial thickness Full-thickness First degree

Full-thickness

Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV? Gay, bisexual, and other men who have sex with men Recreational drug users Blood transfusion recipients Health care providers

Gay, bisexual, and other men who have sex with men

he client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in what position?

HOB elevated, semi-fowler's

The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply. Hypertension Tachycardia Fever Diaphoresis Nasal congestion

Hypertension Diaphoresis Nasal congestion

A client has ascites. Which of the following interventions would the nurse prepare to assist with implementing to help the client control this condition? Select all that apply. Instructing the client to remove salty and salted foods from the diet Administering prescribed spironolactone (Aldactone) Assisting with placement of a transjugular intrahepatic portosystemic shunt Mobilizing the client every 2 hours Taking the client's weight every 3 to 4 days

Instructing the client to remove salty and salted foods from the diet Administering prescribed spironolactone (Aldactone) Assisting with placement of a transjugular intrahepatic portosystemic shunt

When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function? Jaundice Pruritus of the arms and legs Fatigue during ambulation Irritability and drowsiness

Irritability and drowsiness

Which of the following is the effect of protein catabolism in a client with severe burns? It compromises wound healing and immunocompetence. It compromises dexterity and mobility. It maximizes the risk of sodium retention and hypotension. It maximizes the risk of impaired ventilation.

It compromises wound healing and immunocompetence.

Which are correct statements about the relationship between the hypothalamus and the pituitary gland? Select all that apply. Many endocrine glands respond to stimulation from the pituitary gland, which is connected by a stalk to the hypothalamus in the brain. Under the influence of the hypothalamus, the lobes of the pituitary gland secrete various hormones. The pituitary gland is called the master gland because it regulates the function of the hypothalamus and other endocrine glands. The hypothalamus is called the master gland because it regulates the function of the pituitary gland.

Many endocrine glands respond to stimulation from the pituitary gland, which is connected by a stalk to the hypothalamus in the brain. Under the influence of the hypothalamus, the lobes of the pituitary gland secrete various hormones.

The nurse is caring for a patient who has ascites as a result of hepatic dysfunction. What intervention can the nurse provide to determine if the ascites is increasing? (Select all that apply.) Measure urine output every 8 hours. Assess and document vital signs every 4 hours. Measure abdominal girth daily. Perform daily weights. Monitor number of bowel movements per day.

Measure abdominal girth daily. Perform daily weights.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Measuring and documenting the drainage in the collection chamber Maintaining continuous bubbling in the water-seal chamber Keeping the collection chamber at chest level Stripping the chest tube every hour

Measuring and documenting the drainage in the collection chamber

The client is receiving adjuvant chemotherapy for breast cancer. Which is most likely her node status and tumor size? Node negative, tumor size 0.3 cm Node negative, tumor size 0.5 cm Node negative, tumor size 1.2 cm Node negative, tumor size 0.2 cm

Node negative, tumor size 1.2 cm

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest? Respiratory acidosis Paradoxical chest movement Chest pain on inspiration Clubbing of fingers and toes

Paradoxical chest movement

On assessment of a patient with early-stage hypothyroidism, the nurse practitioner assesses for a vague yet significant sign which is: Bradypnea Paresthesia Hypotension Hypothermia

Paresthesia

A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately? CO2 Sodium Chloride Potassium

Potassium

A client has been assessed for aldosteronism and has recently begun treatment. What are priority areas for assessment that the nurse should frequently address? Select all that apply. Pupillary response Creatinine and BUN levels Potassium level Peripheral pulses Blood pressure

Potassium level Blood pressure

The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What is the main purpose of these nursing actions? Prevent gastric ulcers Prevent aspiration Prevent abdominal distention Prevent diarrhea

Prevent aspiration

The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know can be used intravenously? Select all that apply. Rapid-acting Short-acting Intermediate-acting Long-acting

Rapid-acting Short-acting

Which of the following is a true statement regarding the purposes of skin grafts? Increases evaporative fluid loss. Increases potential for infection. Reduces scarring and contractures. Prolongs recovery

Reduces scarring and contractures.

A nurse is caring for a client with suspected hyperparathyroidism. Which condition may contribute to hyperparathyroidism? Renal failure Thyroidectomy Decreased serum calcium level Steroid use

Renal failure

A nurse is completing a nutritional status of a client who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply. Serum albumin level Weight history White blood cell count Body mass index Blood urea nitrogen (BUN) level

Serum albumin level Weight history Body mass index Blood urea nitrogen (BUN) level

Based on her knowledge of the primary cause of end-stage renal disease, the nurse knows to assess the most important indicator. What is that indicator? Blood pressure Urine protein Serum glucose pH and HCO3

Serum glucose

A nursing student assists a registered nurse to admit a client with a primary immunodeficiency. The nurse explains to the student that primary immunodeficiencies predispose people to three conditions. Which of the following three are those conditions? Severe infections Autoimmunity Cancer Malnutrition Phagocytic dysfunction

Severe infections Autoimmunity Cancer

The nurse began transfusing the first unit of packed red blood cells (PRBCs) fifteen minutes ago. The client reports shortness of breath, nausea, and is restless. What is the nurse's priority action? Flush the blood tubing with normal saline. Discontinue the intravenous line. Stop the infusion. Notify the primary health care provider.

Stop the infusion

A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? Psychosocial stress Hypersensitivity to an immunization Menarche Streptococcal infection

Streptococcal infection

The nurse is caring for a client receiving hemodialysis three times weekly. The client has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this client? Using a stethoscope for auscultating the fistula is contraindicated. The client feels best immediately after the dialysis treatment. Taking a BP reading on the affected arm can damage the fistula. The client should not feel pain during initiation of dialysis.

Taking a BP reading on the affected arm can damage the fistula.

A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care? The client will be monitored closely to detect malignant changes. Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. Small amounts of blood are likely to be present in the stools and are not cause for concern. Antacids may be discontinued when symptoms of heartburn subside.

The client will be monitored closely to detect malignant changes.

A patient is receiving chemotherapy for breast cancer. Her most recent laboratory test results are as follows: Erythrocytes 4,500,000/cu mm Hemoglobin 12.0 gm/dL Hematocrit 35% Leukocytes 4,600 gm/dL Thrombocytes 125,000/cu mm Which results suggests some evidence of bone marrow suppression? Erythrocyte count Hemoglobin level Leukocyte count Thrombocyte count

Thrombocyte count

A client is in the hospital with a bleeding gastric ulcer and requires a blood transfusion. He has been typed and crossmatched for 2 units of packed red blood cells and found to have type O blood. What type of blood will the nurse administer to this client? Type A Type B Type AB Type O

Type O

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 Change the transparent dressing every 3 days. Wear a face mask during dressing changes. Assess the PICC insertion site daily. Use clean gloves when providing site care.

Wear a face mask during dressing changes.

A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents? Wear disposable gloves and protective clothing. Break needles after the infusion is discontinued. Disconnect I.V. tubing with gloved hands. Throw I.V. tubing in the trash after the infusion is stopped.

Wear disposable gloves and protective clothing.

Which are possible long-term complications of spinal cord injury? Select all that apply. respiratory arrest areflexia autonomic dysreflexia respiratory infection

autonomic dysreflexia respiratory infection

A client with type 1 diabetes reports waking up in the middle of the night feeling nervous and confused, with tremors, sweating, and a feeling of hunger. Morning fasting blood glucose readings have been 110 to 140 mg/dL. The client admits to exercising excessively and skipping meals over the past several weeks. Based on these symptoms, the nurse plans to instruct the client to administer an increased dose of neutral protamine Hagedorn insulin in the evening. check blood glucose at 3:00 a.m. eat a complex carbohydrate snack in the evening before bed. skip the evening neutral protamine Hagedorn insulin dose on days when exercising and skipping meals.

check blood glucose at 3:00 a.m.

What type of feedings should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions? continuous feedings intermittent feeding bolus feeding cyclic feeding

continuous feedings Bolus or intermittent feedings (every 4-6 hours) cause sudden distention of the small intestine, and cyclic feedings are not advised (same time everyday, pump used).

A client with hepatitis C develops liver failure and GI hemorrhage. The blood products that most likely bring about hemostasis in the client are: whole blood and albumin. platelets and packed red blood cells. fresh frozen plasma and whole blood. cryoprecipitate and fresh frozen plasma.

cryoprecipitate and fresh frozen plasma.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for? diaphoresis, vomiting, and diarrhea. manifestations of electrolyte disturbances. manifestations of hypoglycemia. constipation, dehydration, and hypercapnia.

diaphoresis, vomiting, and diarrhea.

A client with acute pancreatitis has jaundice with diminished bowel sounds and a tender distended abdomen. Additionally, lab results indicate hypovolemia. What will the physician order to treat the large amount of protein-rich fluid that has been released into the client's tissues and peritoneal cavity? Select all that apply. diuretics albumin sodium dextrose solution

diuretics albumin

The most common symptom of esophageal disease is nausea. vomiting. dysphagia. odynophagia.

dysphagia.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: report fluctuations in the water-seal chamber. clamp the chest tube once every shift. encourage coughing and deep breathing. milk the chest tube every 2 hours.

encourage coughing and deep breathing.

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order: naloxone (Narcan). famotidine (Pepcid). nitroglycerin (Nitro-Bid). atracurium (Tracrium).

famotidine (Pepcid).

A physician orders lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor: urine output. abdominal girth. stool frequency. level of consciousness (LOC).

level of consciousness (LOC).

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is: planning for the client's rehabilitation and discharge. providing emotional support to the client and family. maintaining the client's fluid, electrolyte, and acid-base balance. preserving full range of motion in all affected joints.

maintaining the client's fluid, electrolyte, and acid-base balance.

The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question? a low-fat diet elevation of upper body on pillows pantaprazole metoclopramide

metoclopramide The instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa (Sinemet), which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and: sodium. potassium. magnesium. phosphorus.

phosphorus.

A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer: spironolactone (Aldactone). phytonadione (Mephyton). furosemide (Lasix). warfarin (Coumadin).

phytonadione (Mephyton).

Which tests tell the physician what the viral load is in a client with HIV/AIDS? Select all that apply. T4/T8 ratio polymerase chain reaction Western blot p24 antigen test ELISA test

polymerase chain reaction p24 antigen test

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: raccoon's eyes and Battle sign. nuchal rigidity and Kernig's sign. motor loss in the legs that exceeds that in the arms. pupillary changes.

raccoon's eyes and Battle sign.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: elevated liver enzymes and low serum protein level. subnormal serum glucose and elevated serum ammonia levels. subnormal clotting factors and platelet count. elevated blood urea nitrogen and creatinine levels and hyperglycemia.

subnormal serum glucose and elevated serum ammonia levels.

The most significant complication related to continuous tube feedings is the interruption of GI integrity. a disturbance of intestinal and hepatic metabolism. the increased potential for aspiration. an interruption in fat metabolism and lipoprotein synthesis.

the increased potential for aspiration.

A nurse receives her client care assignment. Following the report, she should give priority assessment to the client: with pinkish mucus discharge in the appliance bag 2 days after an ileal conduit. who has a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L 7 days after a kidney transplant. who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L who is experiencing mild pain from urolithiasis.

who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L.

A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes highest priority at this time? Decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired electrical conduction Anxiety related to an actual threat to health status, invasive procedures, and pain Disabled family coping related to knowledge deficit and a temporary change in family dynamics Hypothermia related to exposure to cold temperatures and a long cardiopulmonary bypass time

Decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired electrical conduction

While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea? Evidence of exudate Color of the mucous membranes Deviation from the midline Evidence of muscle weakness

Deviation from the midline

A client on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action? Apply an icepack to the blood that remains to be infused. Discontinue the remainder of the PRBC transfusion and inform the health care provider. Disconnect the bag of PRBCs, cool for 30 minutes and then administer. Administer the remaining PRBCs by the IV direct (IV push) route.

Discontinue the remainder of the PRBC transfusion and inform the health care provider

A client develops a hemolytic reaction to a blood transfusion. What actions should the nurse take after this occurs? Select all that apply. Administer diphenhydramine Begin iron chelation therapy Obtain appropriate blood specimens Collect a urine sample to detect hemoglobin Document the reaction according to policy

Document the reaction according to policy Obtain appropriate blood specimens Collect a urine sample to detect hemoglobin

Anorexia and cachexia are common problems at the end of life. The nurse plays an important role in managing symptoms and preventing complications. Which of the following are appropriate nursing interventions for these problems? Select all that apply. Advise the patient and family about the importance of a balanced diet. Encourage the patient to eat in an upright position. Suggest a daily weighing time to monitor treatment plan. Recommend that the patient eat when hungry, regardless of usual meal times. Teach the patient how to increase the nutritional value of meals (i.e., add dry milk powder to milk).

Encourage the patient to eat in an upright position. Recommend that the patient eat when hungry, regardless of usual meal times. Teach the patient how to increase the nutritional value of meals (i.e., add dry milk powder to

A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client? GM-CSF Erythropoietin Eltrombopag Thrombopoietin

Erythropoietin

The nurse should notify the healthcare provider before administering fresh frozen plasma (FFP) based on which assessment finding? White sclera Jugular venous distention Strong pedal pulses Absence of tenting skin turgor

Jugular venous distention During the pre-transfusion assessment, the nurse should carefully inspect for any signs of cardiac failure, such as jugular venous distention. The sclera should be examined for icterus; white is an expected finding. Weak pedal pulses would be a sign of cardiac failure. Tenting skin turgor is a sign of dehydration; low vascular volume would be a cause for transfusion, not a contraindication.

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? Auscultate the client's abdomen after injecting air through the tube. Assess the color and pH of aspirate. Locate the marking made after the initial x-ray confirming placement. Use a combination of at least two accepted methods for confirming placement.

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

During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis? Recommending that the client discontinue chemotherapy Providing a solution of viscous lidocaine for use as a mouth rinse Monitoring the client's platelet and leukocyte counts Checking regularly for signs and symptoms of stomatitis

Providing a solution of viscous lidocaine for use as a mouth rinse

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level? Cool, moist skin Rapid, thready pulse Arm and leg trembling Slow, shallow respirations

Rapid, thready pulse

A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. Which of the following clinical manifestations would the nurse assess with phlebitis? Select all that apply. Cool area around the insertion site Reddened area along the path of the vein Tender area around the insertion site Ecchymosis at the insertion site Rapid, shallow respirations

Reddened area along the path of the vein Tender area around the insertion site

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms? Serum glucose level of 450 mg/dl Serum glucose level of 52 mg/dl Serum calcium level of 8.9 mg/dl Serum calcium level of 10.2 mg/dl

Serum glucose level of 52 mg/dl

A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? Urine output of 400 ml in 8 hours Serum potassium level of 2.6 mEq/L Blood pressure of 120/64 to 130/72 mm Hg Sodium level of 142 mEq/L

Serum potassium level of 2.6 mEq/L (normal is 3.5-5.5 mEq/L)

The nurse palpates the thyroid gland of a patient suspected of having hyperthyroidism. The nurse documents the positive finding of a gland that is: Tiny in size and difficult to palpate. Hard as a result of hypertrophy. Soft with poorly defined borders. Nodular due to diminished blood flow.

Soft with poorly defined borders.

A client who is to have breast conservation surgery is also to undergo a setinel lymph node biopsy (SLNB). Which of the following would the nurse include in the client's preoperative teaching plan? The client will most likely be admitted for an overnight stay. The client's urine may have a blue-green discoloration in the first 24 hours. The client has an increased risk for developing lymphedema. The client will need less emotional support because the procedure is less invasive.

The client's urine may have a blue-green discoloration in the first 24 hours.

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. The incubation period for this virus is up to 4 months. 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. There is a 50% risk that cirrhosis will develop.

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.

A nurse is aware that several laboratory results are present in a patient diagnosed with diabetes insipidus. Select all that apply. Urine specific gravity of 1.001 Serum ADH level of 2.3 pg/mL Serum osmolality of 310 mOsm/kg Urine osmolality of 800 mOsm/kg Serum sodium level of 149 mEq/L

Urine specific gravity of 1.001 Serum osmolality of 310 mOsm/kg Serum sodium level of 149 mEq/L

A nurse is teaching a group of women about the potential benefits of breast self-examination (BSE). The nurse should teach the women that effective BSE is dependent on what factor? Women's knowledge of how their breasts normally look and feel The rapport that exists between the woman and her primary care provider Synchronizing women's routines around BSE with the performance of mammograms Women's knowledge of the pathophysiology of breast cancer

Women's knowledge of how their breasts normally look and feel

The nurse is caring for a client who has a peripheral IV in place for fluid replacement. When caring for the client's IV site, the nurse should: ensure that anticoagulants are placed on hold for the duration of IV therapy. replace the IV dressing with a new, clean dressing if it is soiled. ensure that the tubing is firmly anchored to the client's skin. periodically remove hair from 2 cm around the IV site.

ensure that the tubing is firmly anchored to the client's skin.

The nurse prepares to administer all of a client's medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes which type of oral medication on the client's medication administration record? simple compressed tablets buccal or sublingual tablets enteric-coated tablets soft, gelatin capsules filled with liquid

enteric-coated tablets

A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What client mostlikely faces the highest immediate risk of oral cancer? A 65-year-old man with alcoholism who smokes A 45-year-old woman who has type 1 diabetes and who wears dentures A 32-year-old man who is obese and uses smokeless tobacco A 57-year-old man with GERD and dental caries

A 65-year-old man with alcoholism who smokes

Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome? Administer 2 to 3 L of IV fluid rapidly. Administer 10 L of IV fluid over the first 24 hours. Administer a dextrose solution containing normal saline solution. Administer IV fluid slowly to prevent circulatory overload and collapse.

Administer 2 to 3 L of IV fluid rapidly.

Which of the following is the most common cause of symptomatic hypomagnesemia in the United States? Alcoholism Intestinal resection Inflammatory bowel disease Loss of gastric acid

Alcoholism

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply. Hypotension Tachycardia Venous pooling Diaphoresis Tachypnea Hypothermia

Hypotension Venous pooling Tachypnea Hypothermia

Which of the following types of shock will a nurse observe in a client with extensive burns? Anaphylactic shock Neurogenic shock Septic shock Hypovolemic shock

Hypovolemic shock

A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action? Immediate craniotomy An order for a head computed tomography scan Intubation and mechanical ventilation IV administration of propofol

Immediate craniotomy

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for? Bleeding Iodine allergy Dysrhythmias Inflammation

Iodine allergy

A hospitalized, insulin-dependent patient with diabetes has been experiencing morning hyperglycemia. The patient will be awakened once or twice during the night to test blood glucose levels. The health care provider suspects that the cause is related to the Somogyi effect. Which of the following indicators support this diagnosis? Select all that apply. Normal bedtime blood glucose Rise in blood glucose about 3:00 AM Increase in blood glucose from 3:00 AM until breakfast Decrease in blood sugar to a hypoglycemic level between 2:00 to 3:00 AM Elevated blood glucose at bedtime

Normal bedtime blood glucose Increase in blood glucose from 3:00 AM until breakfast Decrease in blood sugar to a hypoglycemic level between 2:00 to 3:00 AM

A client, aged 75, is diagnosed with a renal disease and administered nephrotoxic drugs in normal doses. The nurse is aware that it is important to observe the client closely for any changes in renal status. Which of the following measures may help a nurse determine a change in renal status? Observing the client's fluid intake. Checking for a thrill or a bruit daily. Observing the client's urinary output. Observing the skin color and nail beds.

Observing the client's urinary output.

A 18-year-old client presents to the emergency department with a severe open fracture of the lower extremity. The health care provider tells the client that the client will need a blood transfusion. The client refuses, despite the advise of the health care provider. What does the nurse understand is the legal implication of the scenario? The client has a right to refuse the transfusion. The health care provider may first call the client's parents if the client refuses. The client can only refuse the transfusion if the consent form has not been signed. The health care provider may ask for a court order if the client refuses.

The client has a right to refuse the transfusion.

A nurse is caring for a client who needs a nasogastric (NG) tube for a tube feeding. What is the safe method for the nurse to use to measure the appropriate length of the NG tube? A length of 50 cm (20 in) The distance measured from the nose to the xiphoid process The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process The distance measured from the tragus of the ear to the xiphoid process

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