RN Adult Med surg online Practice A

A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings? - Dysphagia - Aphasia - Ataxia - Hemianopsia

Dysphasia Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding.

A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer?

Dyspnea Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the clients breathing and improve comfort.

A nurse is assessing a client who has advanced lung cancer is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer? - Dyspnea - Hemoptysis - Mucus production -Dysphagia

Dyspnea Rationale: Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing and improve comfort.

A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? - Heart rate 110/min - Blood pressure 138/90 mm Hg - Urine specific gravity 1.020 - BUN 15 mg/dL

Heart rate 110/min A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate.

A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions? - Neutralizing gastric acid -Reducing the growth of ulcer-causing bacteria - Coating the stomach lining - Suppressing gastric acid production.

- Suppressing gastric acid production Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production.

A nurse is providing teaching to a female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching? - Taking my daily progesterone should improve my symptoms - A risk factor for my condition is obesity - I should limit my daily fluid intake - I will switch my morning cup of coffee to hot tea

A risk factor for my condition is obesity Excess weight creates increased abdominal pressure that can result in stress incontinence.

A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first?

Call for help. Rationale: Evidence-based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock. Therefore, the nurse should obtain immediate assistance.

A nurse is caring for a client who has portal hypertension. The client is vomiting mixed blood with food after a meal. Which of the following actions should the nurse take first? - Check laboratory values for recent hemoglobin and hematocrit levels. - Establish a peripheral IV line for possible transfusion - Call the laboratory to obtain a stat platelet count. - Obtain vital signs.

- Obtain vital signs Rationale: The first action the nurse should take using the nurse process is to assess the clients vital sign's. A client who has HTN can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making.

A nurse is teaching a class about client rights. Which of the following instructions should the nurse include? - A client should sing an informed consent before receiving a placebo during research trial - A client cannot refuse to sign a consent form for a life-saving treatment. - A client who has a mental illness is unable to give informed consent. -A unemancipated minor needs guardian consent for substance use disorder treatment.

A client should sign an informed consent before receiving a placebo during a research trial. A nurse should ensure a client has provided informed consent before administering a placebo. Placebos should not be used outside of approved clinical research in which the client has consented to participate.

A nurse is assessing a group of clients for indication of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change?

A client who has multiple sclerosis and is experiencing progressive difficulty ambulating. Rationale: The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change and the client become less independent.

1000 Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestation started about 30 mins ago. Client reports flashing lights in their vision, especially on the right side. Clients partner states the client had some difficulty with finding words when speaking. Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain. 1045 Client states the flashing lights, numbness, and tingling in the lips have gone away. Client states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is requesting medication for pain that is 7 on a scale of 0 to 10. Hand grasps are equal and strong bilaterally. The nurse should identify that the client is most likely experiencing_____ and the nurse should address the client's ______

A migraine - The client is exhibiting manifestations of a migraine. The client presented initially with neurological manifestations of flashing lights, aphasia, unilateral weakness, and numbness of the lips. These findings are consistent with the first phase, or aura, phase, of a migraine. These changes resolved after an hour and were followed by throbbing pain with nausea and vomiting. Pain - The client reports pain as 7 on a scale of 0 to 10, which indicates significant discomfort. The nurse should address the client's pain level to promote comfort.

A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis? - Metabolic alkalosis - Hyperkalemia - Increased hemoglobin - Hypophosphatemia

Hyperkalemia The nurse should identify that a client who has chronic glomerulonephritis can experience hyperkalemia as a result of kidney failure. Kidney failure results in decreased excretion of potassium

A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? - Add full-fat yogurt to the diet - Add cabbage to the diet - Replace butter with coconut oil - Replace shellfish with red meat

Add cabbage to the diet To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.

1000 Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestation started about 30 mins ago. Client reports flashing lights in their vision, especially on the right side. Clients partner states the client had some difficulty with finding words when speaking. Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain. 1045 Client states the flashing lights, numbness, and tingling in the lips have gone away. Client states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is requesting medication for pain that is 7 on a scale of 0 to 10. Hand grasps are equal and strong bilaterally. A nurse is caring for a client who has a migraine. Which of the following interventions should the nurse anticipate?

Administer Sumatriptan - The nurse should plan to administer a medication, such as sumatriptan, to produce cerebral artery vasoconstriction and relieve the client's manifestation. Dim the lights in the clients room - The nurse should plan to dim the lights in the clients room to promote comfort because the client is experiencing photophobia.

A nurse is caring for a client who is receiving TPN. A new bag is not available when the current infusion is nearly complete. Which of the following actions should the nurse take?

Administer dextrose 10% in water until the new bag arrives.

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority? - Obtaining vital signs - Placing the client in Fowler's position - Administering epinephrine - Initiating an IV infusion of 0.9% sodium chloride

Administering epinephrine Evidence-based practice indicated that the priority intervention is for the nurse to administer epinephrine quickly to dilate the bronchioles and prevent circulatory shock.

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? - Increase intake of foods containing calcium - Alternate application of heat and cold to the affected joints. - Keep the affected extremities elevated - Limit movement of the affected joints.

Alternate application of heat and cold to the affected joints. The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and pain. The application of cold can relieve joint swelling and the application of heat can decrease joint stiffness and pain.

A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessments findings should the nurse expect?

Hypoactive bowel sounds Rationale: Hypokalemia decreases smooth muscle contraction in the GI leading to decreased peristalsis.

A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires re-evaluation of the IV therapy prescription? Temperature - 98.8 HR - 88/min RR 18/min BP - 118/6/ O2 96% Pain - 0 Hgb- 15.1 Hct - 54.2% BUN - 292 Sodium 145 Potassium 4.7

BUN - The clients HCT and BUN levels indicate dehydration and require an increase in the IV fluid infusion rate.

A nurse in an emergency department is assessing an older client who has a fractured wrist following a fall. During the assessment, the client states "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority. - Check the client's neurologic status - Document the client's statements - Prepare the client for a CT scan - Teach the client about using safety precautions for falls.

Check the clients neurologic status - The first action the nurse should take using the nursing process is to assess the client/ Therefore, the nurse should first check the neurologic status of the client.

1000 Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestation started about 30 mins ago. Client reports flashing lights in their vision, especially on the right side. Clients partner states the client had some difficulty with finding words when speaking. Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain. 1045 Client states the flashing lights, numbness, and tingling in the lips have gone away. Client states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is requesting medication for pain that is 7 on a scale of 0 to 10. Hand grasps are equal and strong bilaterally. Following administration of sumatriptan, the nurse should monitor for _______, due to the risk of _____

Chest pain - The nurse should monitor the client for chest pain because sumatriptan can cause coronary vasospasm. Myocardial ischemia - Sumatriptan can cause vasospasm, which can lead to myocardial ischemia.

The nurse is caring for a client 1hr following chest tune insertion. - Client reports pain as 3 on a scale of 0 to 10 - Client reports shortness of breath has decreased - Client reports nausea, awaiting prescription for nausea. - Transfused 1 unit of packed RBCs, awaiting second unit. - Wound dressing is dry and intact - Respiratory rate 24/min - Blood pressure 108/74 mm Hg - Oxygen saturation of 95% on 2 L/min via nasal cannula.

Client reports pain as a scale of 0 to 10. - Rationale: The nurse should identify that the clients pain has decreased, indicating their condition is improving. Client reports SOB is decreasing. - Rationale: The nurse should identify that the client's SOB has decreased, indicating their condition is improving. Wound dressing is dry and intact. - Rationale: The nurse should identify that a dry and intact wound dressing indicates the client's wound is no longer bleeding. Respiratory rate 24/min, blood pressure 108/74 mmHg, and oxygen saturation 95% on 2L/min via nasal cannula Rationale: The nurse should identify that the clients vitals signs have improved, indicating hemodynamic function.

A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain? - Set the wall suction to 80 to 100 mmHg - Compress the drain reservoir after emptying - Allow the drainage to collect on a sterile gauze dressing. - Position the drain below the bed to promote drainage.

Compress the drain reservoir after emptying Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the drain, and into the reservoir.

A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect? - Constipation - Insomnia - Tachycardia - Diaphoresis

Constipation Rationale: A client who has hypothyroidism can experience constipation due to decrease in the clients metabolism, resulting in slow motility of the GI tract. The nurse should instruct the client to increase fiber and fluid intake to reduce the risk for constipation

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take? - Check the clients blood glucose according to the facility mealtimes. - Contact the provider to clarify the prescription - Request for meals to be provided for the client - Hold the prescription until the client is no longer NPO

Contact the provider to clarify the prescription. Rationale: Mealtimes do not pertain to this client due to the NPO status. The nurse should monitor the client's glucose levels on a set schedule, either every 6hrs or per facility protocol. Thus, the prescription requires clarification

A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication?

Crackles heard on auscultation Mannitol is an somatic diuretic that prevents dogs reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the grain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestations of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation. .

A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication? - Decreased heart rate. - Crackles heard on auscultation - Increased urinary output - Decreased deep tendon reflexes

Crackles heard on auscultation. Rationale: Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestations of pulmonary edema and notify the provider. Other manifestations include dyspnea and oxygen saturation.

A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make? - Discontinuing with treatments is your choice if it is your wish to do so. - Your child is named as your healthcare surrogate. I will ask them if you can stop the treatments. - I will call your spiritual advisor to come in, so you can discuss this with them. - Next time you have an oncology appointment, you should ask the oncologist

Discontinuing with the treatment is your choice if it is your wish to do so. Rationale: The nurse should recognize the client's right to refuse the treatments and inform the client of this right. The nurse should advocate for the client and offer to contact the provider for the client.

A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement? - Place a padded tongue blade at the client's beside - Keep the side rails lowered on the client's bed. - Maintain the client's bed at hip level or above - Ensure that the clients has a patent IV

Ensure that the client has a patent IV The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.

A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? - Extremity cool upon palpation - Serosanguineous drainage on the dressing - Capillary refill of 2 seconds - Client report of discomfort when moving toes

Extremity cool upon palpataion Rationale: The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome.

A nurse is providing education to a client who has TB and their family. Which of the following information should the nurse include in the teaching? - After 1 week of medication. TB is no longer communicable - Dispose of contaminated tissues in a paper bag. -Airborne precautions are necessary in the home - Family members in the household should undergo TB testing.

Family members in the household should undergo TB testing. Family members who live in the same household with the client have been exposed to TB. Therefore, the nurse should recommend TB screening to foster early detection and treatment of TB.

A nurse is preparing a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? - Follow a smoking cessation program. - Maintain an appropriate weight - Eat a low-fat-diet - Increase fluid intake - Decrease intake of complex carbohydrates.

Follow a smoking cessation program. Rationale: Smoking cessation is an important lifestyle modification to prevent atherosclerosis. Maintain an appropriate weight. Rationale: Preventing obesity through diet and exercise can help to prevent atherosclerosis. Eat a low fat diet. Rationale: Eating a low fat diet decreases LDL, cholesterol, and can prevent atherosclerosis.

1000: Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestations started about 30 min ago. Client reports flashing lights in their vision, especially on the right side. Client's partner states the client had some difficulty with finding words when speaking. Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain. 1045: Client states the flashing lights, numbness, and tingling in the lips have gone away. Client states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is requesting medication for pain that is 7 on a scale of 0 to 10. Hand grasps are equal and strong bilaterally.

Following the administration of sumatriptan, the nurse should monitor for due to the risk of Chest pain. - The nurse should monitor the client for chest pain because sumatriptan can cause coronary vasospasms. Myocardial ischemia- Sumatriptan can cause coronary vasospasms, which can lead to myocardial ischemia.

A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the followoing laboratory values should the nurse report to the provider. - Potassium 4 mEq/L - WBC count 10,000/mm3 - Hct 45% - Hgb 8g/dL

Hgb 8g/dL Rationale: The nurse should report an Hgb level of 8g/dL, which is below the expected reference range and is an indicator of postoperative hemorrhage or anemia.

1000 Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestation started about 30 mins ago. Client reports flashing lights in their vision, especially on the right side. Clients partner states the client had some difficulty with finding words when speaking. Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain. 1045 Client states the flashing lights, numbness, and tingling in the lips have gone away. Client states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is requesting medication for pain that is 7 on a scale of 0 to 10. Hand grasps are equal and strong bilaterally. The nurse is evaluating the clients understanding of discharge instructions. Which of the following client statements indicates and understanding of the teaching?

Foods that contain tyramine might trigger my headaches - Tyramine - containing foods, such as aged cheeses, smoked sausages, pickles, and beer are common triggers for migraines. I will keep a food and headache diary - The nurse should instruct the client to keep a food and headache diary to identify migraine triggers. I will place a cool cloth on my forehead when I experience a migraine - The nurse should instruct the client to lie dow, dim the lights, and place a cool cloth on the forehead to relive migraine pain.

The nurse is evaluating the client's understanding of discharge instructions. Which of the following client statements indicates an understanding of the teaching?

Foods that contain tyramine might trigger my headaches" is Tyramine-containing foods, such as aged cheeses, smoked sausage, pickles, and beer are common triggers for migraines. "I will keep a food and headache diary". The nurse should instruct the client to keep a food and headache diary to identify migraine triggers. "I will place a cool cloth on my forehead when I experience a migraine". The nurse should instruct the client to lie down, dim the lights, and place a cool cloth on the forehead to relieve migraine pain.

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? - Ginkgo biloba relieves nausea for people who have vertigo - Taking ginkgo biloba will help relieve your joint pain Ginkgo biloba can cause an increased risk for bleeding - Taking ginkgo biloba decreases the risk of migraine headache

Ginkgo biloba can cause an increased risk for bleeding. Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with peripheral artery disease. The supplement also decreases platelet aggregation, which in turn increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba without first speaking with their provider.

1000 Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestation started about 30 mins ago. Client reports flashing lights in their vision, especially on the right side. Clients partner states the client had some difficulty with finding words when speaking. Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain.

Hand grasps is consistent with migraine, stroke, and meningitis. Unitlateral weakness can occur due to neurological vascular changes and inflammation that can be present with migrain, stroke, and meningitis. Numbness is consistent with migraine and stroke. Numbness and tingling of the lips and tongue can occur with migraines due to neurological vascular changes and inflammation that be present. Numbess can also occur with middle cerebral artery strokes. Aphasia is consistent with migraine and stroke. Aphasia can occur due to neurological vasuclar changes and inflammation that can be present. Family history is consisten with migraine and stroke. Family history is a risk factor associated with migraine and stroke.

A nurse is providing instructions to a client who has type 2 diabetes and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching? - I will monitor my blood sugar carefully because the medication increases the secretion of insulin - I should take this medication with meals - I can expect to gain weight while taking this medication - While taking this medication, I will experience flushing of my skin.

I should take this medication with a meal The client should take metformin with or immediately following meals to improve absorption and to minimize GI distress.

A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching?

I will avoid direct exposure to the sun Rationale: the client should avoid exposure of irradiated skin areas for at least 1 year after completing radiation therapy. Skin in the radiation path is especially sensitive to sun damage.

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? - I will monitor my blood pressure while taking this medication - I should take a vitamin D supplement to increase the effectiveness of the medication - I should inform the provider if I experience an increased appetite while taking this medication - I will decrease the amount of protein in my diet while taking this medication

I will monitor my blood pressure while taking this medication The client should monitor their blood pressure while taking this medication because HTN is a common adverse effect and can lead to hypertensive encephalopathy.

A nurse in an emergency department is caring for a client who has full - thickness burns over 20% of their body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer?

IV fluids After establishing that the clients airway is secure and administering oxygen, evidence-based practice indicates that the nurse,should prepare to administer IV fluids to provide circulatory support.

A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first? -IV fluids - Analgesia - Antibiotics - Tetanus toxoid

IV fluids Rationale: After establishing that the clients airway is secure and administering oxygen, evidence-based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support.

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? - Older adult clients might require up to 6 grams of acetaminophen over 24 hours for effective pain control - Ibuprofen can cause GI bleeding in older adult clients. - Meperidine is the medication of choice for older adult clients experiencing severe pain. - Older adult clients taking oxycodone are at risk for diarreha.

Ibuprofen can cause GI bleeding in older adult clients. A common adverse effect of ibuprofen is GI bleeding, and adult clients have an increased risk for GI toxicity and bleeding.

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

Ibuprofen can cause gastrointestinal bleeding in older adult clients A common adverse effect of ibuprofen is gastrointestinal bleeding, and older adult clients have an increased risk for gastrointestinal toxicity and bleeding.

A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide? - Increase fluid intake - Take an over-the-counter antidiarrheal medication - Expect black, tarry stools - Follow a low-fiber diet.

Increase fluid intake Increasing fluid intake will help prevent constipation. Therefore, the nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test.

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pna. Which of the following assessment findings is the nurses priority?

Increased respiratory secretion. Rationale: Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. Clients who have ALS may experience respiratory muscle weakness and dysphagia, and excessive respiratory secretions can impair the ability to clear the airway, which increases the client's risk for aspiration.

A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first?

Initiate airborne precautions This client is exhibiting manifestations of tuberculosis. The greatest risk I'm this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions

A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and productive cough. Which of the following actions should the nurse take first? - Obtain a sputum sample - Administer antipyretics - Provide hand hygiene education - Initiate airborne precautions.

Initiate airborne precautions. Rationale: This client is exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions

A nurse is caring for a client who is postoperative. Vital signs - Temperature 99.7 Heart Rate - 114/min RR - 22/min Blood pressure 88/54 O2 - 93%

Insert large - gauge IV and initiate a fluid challenge because the client is most likely experiencing hypovolemia as evidenced by the client's restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine output. The nurse should monitor the client's urine output and blood pressure to evaluate the effectiveness of treatment.

An emergency nurse is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?

It's like a curtain closed over my eye. Rationale: A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field.

A nurse is caring for a client who is experiencing tonic-clonic seizure. Which of the following actions should the nurse take? - Insert a padded tongue blade - Apply oxygen - Restrain the client - Loosen restrictive clothing

Loosen restrictive clothing The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.

A nurse is administering packed red blood cells to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?

Low back pain Hemolytic transfusion reaction results from the infusion of incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension

A nurse is adminstering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? - Anorexia and jaundice - Bronchospasm and urticaria - Hypertension and bounding pulse - Low back pain and apprehension

Low back pain and apprehension. Rationale: Hemolytic transfusions reactions result from the infusion of incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.

A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan? - Monitor the client's temperature every 4 hrs - Insert an indwelling urinary catheter for the client - Request the client's bathroom to be cleaned three times each weeks - Place a box of latex gloves just outside the client's room

Monitor the client's temperature every 4 hrs The nurse should monitor the temperature of a client who is neutropenia every 4hr because of the client's reduced amount of leukocytosis greatly increases the client's risk for infections.

Client presents with abdominal pain in the upper left quadrant for the past two days. States pain became worse this morning and is radiating to the back. Rates pain as 8 on a scale of 0 to 10. Hypoactive bowel sounds; reports nausea, no vomiting; client is passing flatus. Febrile, oriented to person, place and time. Tachypnea with diminished breath sounds. Sinus tachycardia. Client voids 300mL of clear, amber urine. 0930: Client vomited 100mL brown liquid

Pancreatitis - The clients laboratory results and physical assessment indicate the client is experiencing manifestations of pancreatitis. Client who have pancreatitis experience an increase in pancreatic enzymes, amylase, and lipase Amylase and lipase - The client's laboratory results and physical assessment indicate the client is experiencing manifestations of pancreatitis. Clients who have pancreatitis experience an increase pancreatic enzymes, amylase, and lipase

A nurse has received report on a client who is being admitted to the emergency department. Nurses note: 2330- Report received from ambulance crew: Client has a penetrating wound to the anterior upper right chest. Client is alert and oriented with a Glasow Coma Scale (GCS) score of 15. Client's shirt covered with bright red blood. Client reports pain as 6 on a scale of 0 to 10. Shortness of breath noted Select 3 findings that require follow-up by the nurse - GCS score - Temperature - Wound drainage - Oxygen level - Pain level

Oxygen level Rationale: The client has an oxygen saturation that is less than the expected reference level, indicating hypoxia. The nurse should plan to increase the client's supplement oxygen. Pain - Rationale: The nurse should follow up on the client's pain level Wound drainage: Rationale: The nurse should apply a pressure dressing to control bleeding.

1000 Client is alert and oriented and reports not feeling well for a few days. Client is on continuous ambulatory peritoneal dialysis (CAPD) and reports dialysate appeared cloudy this morning. Reports abdominal pain as 4 on a scale of 0 to 10. Bowel sounds active in all quadrants. Peritoneal dialysis access site red, warm to touch, with a small amount of purulent drainage noted on dressing. 1300: Client is lying in bed with the knees flexed, guarding the abdomen. Abdomen is slightly distended, hypoactive bowel sounds. Client reports nausea. Reports pain as 6 on a scale of 0 to 10. Provider notified and updated with client condition and diagnostic results.

Peritonitis - The client is experiencing manifestations of peritonitis, such as abdominal pain, cloudy dialysate, and an elevated white blood cell count. X-ray results - the clients abdominal x-ray shows fluid in the abdomen along with inflammation, both of which are indications of peritonitis.

A nurse is caring for a client who is 12hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? - Maintain adduction for client's legs - Encourage range of motion of the hip up to a 120 angle - Place a pillow between the client's legs - Keep the client's hip internally rotated.

Place a pillow between the client's legs. The nurse should place a pillow between the client's legs to prevent hip dislocation.

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? - Flush the line before administering antibiotics - Position the client in Trendelenburg to obtain measurements. - Have the client bear down when readings are obtained. - Place a pressure bag around the flush solution

Place a pressure bag around the flush solution. Rationale: The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line.

The nurse is caring for the client following placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? -Place two rubber-tipped hemostats in the client's room - Ensure that all chest tube connections are securely attached. - Strip the drainage tubing to ensure it is patent. - Monitor drainage every 30 mins for the first hour. - Palpate the chest tune insertion site for the subcutaneous emphysema. - Ensure there is continuous bubbling in the water seal chamber. - Place the client in high-fowlers position

Place the client in high fowlers position. - Rationale: The nurse should place the client in high-fowlers position to promote drainage of the hemothorax. Place two rubber-tipped hemostats in the client's room - Rationale: The nurse should place two rubber-tipped hemostats in the clients room to use in case of an emergency, such as chest tube dislodgement. Palpate the chest tube insertion site for subcutaneous emphysema - Rationale: The nurse should palpate the chest tube insertion site for subcutaneous emphysema because this manifestation of an air leak. Ensure that all chest tube connections are securely attached. Rationale: The nurse should ensure that all connections between the chest tube and drainage system are secure and intact to reduce the risk of a tension pneumothorax.

A nurse in a provider's office is assessing a client who has hypertension and takes propanolol. Which of the the findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication? - Report night cough - Report of tinnitus - Report of excessive tearing - Report of increased salivation

Report of a night cough Rationale: The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider.

A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulation, the nurse should provide which of the following instructions to the client? - Wear an eye patch over one eye - Make sure to have a staff member walk on your stronger side. - Scan the environment by turning your head from side to side - Make sure to look at your feet while walking.

Scan the environment by turning your head from side to side Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head form side to side helps enlarge a client's visual field. This technique is also useful for the client during mealtimes.

A nurse is providing follow - care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider? - Sedimentation rate - Hematocrit - Calcium - Acid phosphatase

Sedimentation rate Rationale: An increased rate occurs when a client has any type of inflammatory process, such as osteomyelitis.

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?

Slow the infusion rate. Rationale: Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breathe, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload.

A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6hr ago. Which of the following findings should the nurse expect? - Stone fragments in the urine - Fever - Decreased urine output - Bruising on the lower abdomen

Stone fragments in the urine ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones.

1000: Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestations started about 30 min ago. Client reports flashing lights in their vision, especially on the right side. Client's partner states the client had some difficulty with finding words when speaking. Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain. 1045: Client states the flashing lights, numbness, and tingling in the lips have gone away. Client states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is requesting medication for pain that is 7 on a scale of 0 to 10. Hand grasps are equal and strong bilaterally.

Sumatriptan - The nurse should plan to administer a medication, such as sumatriptan, to produce cerebral artery vasoconstriction and relieve the client's manifestations. Dim the lights - The nurse should plan to dim the lights in the client's room to promote comfort because the client is experiencing photophobia.

A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan?

Tell the client that it is possible to return to similar previous level of activity. The nurse should help the client develop realistic goals and activities to have a productive life.

A nurse is planning care todecrease psychosocial health issues for a client who is starting dialysis treatment for chronic kidney disease. Which of the following interventions should the nurse include in the plan? - Remind the client that dialysis treatments are not difficulty to incorporate into daily life. - Inform the client that dialysis will result in a cure - Tell the client that it is possible to return to similar previous levels of activity. - Begin health promotion teaching during the first dialysis treatment.

Tell the client that it is possible to return to similar previous levels of activity. Rationale: The nurse should help the client develop realistic goals and activities to have a productive life.

A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority? - Moderate sesrosanguinous drainage on the dressing. - Calcium 9.5 mg/dL - Temperature 102F - Decreased bowel sounds

Temperature - 102 When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to the provider because it can lead to seizures and coma.

The nurse is caring for the client. Nurses note: 2330- Report received from ambulance crew: Client has a penetrating wound to the anterior upper right chest. Client is alert and oriented with a Glasow Coma Scale (GCS) score of 15. Client's shirt covered with bright red blood. Client reports pain as 6 on a scale of 0 to 10. Shortness of breath noted. 2345: Client is alert and oriented with GCS score of 15. Client has penetrating wound to the anterior right upper chest measuring 2.5cm (1in.). No other wounds or injuries found. Bilateral radial and pedal pulses are +1. Left lung sounds are clear, right upper lund sounds diminised. Client still reports pain as 6 on a scale of 0 to 10. Bowel sounds are present in all 4 quadrants.

The client is most likely experiencing a hemothorax, as evidenced by the client's respiratory findings. Hemothorax - The client has shortness of breath, hypoxia, diminshed breath sounds, and a decreased hematocrit. Therefore, the client is likely experiencing a hemothorax. Respiratory findings -

A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? - The client starts to cough - The client's heart rate increases - The client is diaphoretic - The client's blood pressure decreases

The client's heart rate increases Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen/ The nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia.

A nurse is caring for a client who is having a seizure. Which of the following intervention is the nurse's priority? - Loosen the clothing around the clients neck - Check the client's pupillary response. - Turn the client to the side. - Move furniture away from the client.

Turn the client to the side. Rationale: The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration

A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority

Turn the client to the side. The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side- lying position to prevent aspiration

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take? - Apply a wet-to-dry gauze dressing. - Irrigate with hydrogen peroxide solution - Use a 30-mL syringe - Attach a 24-gauge angiocatheter to the syringe.

Use a 30-mL syringe The nurse should use a 30-mL syringe with an 18-or-19- gauge catheter to deliver the ideal pressure of 8 pounds per square in (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.

Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestation started about 30 mins ago. Client reports flashing lights in their vision, especially on the right side. Clients partner states the client had some difficulty with finding words when speaking. Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain. Select 4 findings that require follow up by the nurse

Visual disturbances, tingling of the lips, hand grasps, expressive aphasia.

A nurse is reviewing the laboratory result of a client who has aplastic anemia. Which of the following findings indicates a potential complication? - RBC count 5.2 million/mm3 - WBC - count 2,000/mm3 - Platelets 380,000/mm3 - Potassium 4 mEq/L

WBC count 2,000/mm3 A WBC of 2,000/mm3 is below the expected reference range and indicates a risk for severe immunosuppression.

A nurse is providing teaching to a client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching? - It is an expected effect to sleep through the day when taking this medication - Your constipation will be lessened as you develop a tolerance to this medication - You should void every 4 hours to decrease the risk of urinary retention - If you experience ringing in your ears, your dose will need to be reduced.

You should void every 4 hours to decrease the risk of urinary retention. The nurse should instruct the client to void at least every 4hrs to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics.

A nurse is providing teaching to a client who has stage 2 cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse indicate? - "you will have an implant placed twice each month for the duration of the treatment' - "You should remain at least 6 feet away from others between treatments" - You should expect to have blood in your urine for a few days after treatment" - You will need to stay in bed during each treatment session"

You will need to stay in bed during each treatment session Rationale: The nurse should instruct the client that they will need to remain in bed with very limited movement because excessive movement can cause the radioactive source to become dislodged.

A nurse is providing follow up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider?

sedimentation rate An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis.