RN Adult Medical Surgical Online Practice 2019 A for NGN

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" "I will keep a food and headache diary" "I will place a cool cloth on my forehead when I experience a migraine" "Foods that contain tyramine might trigger my headaches" is correct. 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" is correct. 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" is correct. The nurse should instruct the client to lie down, dim the lights, and place a cool cloth on the forehead to relieve migraine pain. "I will take the sumatriptan once every day" is incorrect. Sumatriptan is not administered to prevent a migraine, rather, it is used to treat an occurring migraine. The nurse should instruct the client to take the sumatriptan only as needed for migraine pain. "I should stay awake until my headache is gone" is incorrect. The nurse should instruct the client to lie down, dim the lights, and place a cool cloth on the forehead to relieve migraine pain. The client should be encouraged to sleep until the migraine is resolved.

A nurse is providing teaching to an older adult 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?

"I am dieting to lose weight." Excess weight creates increased abdominal pressure that can result in stress incontinence.

A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching?

"I am taking this medication to increase my energy level." The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance.

A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?

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

A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change?

"I used to never worry about my feet. Now, I inspect my feet every day with a mirror." This statement indicates that the client is successfully coping with the change because the client is performing preventive foot care to reduce the risk for complications.

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

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"I will use my hands rather than a washcloth to clean the radiation area." The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation.

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching?

"You should cut the opening of the skin barrier one-eighth inch wider than the stoma." The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine.

A nurse is providing teaching to an older adult 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?

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

A nurse in a providers office is caring fro a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make?

"You will not be able to use sildenafil if you are taking nitroglycerin." The client should not use sildenafil when taking nitroglycerin because both medications can cause vasodilation and lead to significant hypotension.

A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

167 X mL/hr = Volume (mL)/Time (hr) X mL/hr =4000mL/24 hr X mL/hr = 166.67 Round if necessary. 166.67 = 167 mL/hr

A nurse is teaching a class about client rights. Which of the following instructions should the nurse include?

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. The nurse should not administer a placebo to a client who thinks it is an active medication, because this action is a violation of client rights.

A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse assess first?

A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet When using the stable vs. unstable approach to client care, the nurse should assess this client first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual nitroglycerin tablet could be unstable. This client might be experiencing angina or could be having another MI.

A nurse is assessing a group of clients for indications 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 The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change as the client becomes less independent.

A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients?

A client who is receiving preoperative teaching for a right knee arthroplasty The nurse should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions.

The nurse should identify that the client is most likely experiencingSelect...and the nurse should address the client's Select...

A migraine Pain Dropdown 1 A migraine is correct. 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. A stroke is incorrect. A client who is experiencing a stroke will have neurological manifestations; however, these changes would not resolve after 1 hr. Meningitis is incorrect. A client who is experiencing meningitis will have neurological manifestations; however, these changes would not resolve after 1 hr. Dropdown 2 Blood pressure is incorrect. Although the client's blood pressure is mildly elevated, it does not require intervention by the nurse. Pain is correct. 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. Neurological status is incorrect. The client's neurological changes have resolved. Therefore, this finding does not require intervention by the nurse.

A nurse is caring for a client who was just admitted from the emergency department (ED)

Acute chest syndrome and pneumonia Fluid volume overload is incorrect. While the client is experiencing an increased respiratory rate and shortness of breath, fluid volume overload typically includes moist crackles on auscultation, pitting edema in dependent areas, neck vein distension, and hypertension. Right-sided heart failure is incorrect. While clients who have sickle-cell disease are at risk for developing heart failure, the client does not have manifestations of right-sided heart failure. Right-sided heart failure typically presents with signs of fluid volume overload, which includes jugular vein distention, dependent edema, and blood pressure alterations. Acute chest syndrome is correct. The client is most likely experiencing acute chest syndrome, which can be caused by respiratory infections and debris from sickled cells. The client is displaying manifestations of acute chest syndrome, which include cough, shortness of breath, wheezing, tachypnea, fever, and chest pain. Pneumonia is correct. The client is most likely experiencing pneumonia as evidenced by the manifestations of cough, shortness of breath, fever, tachypnea, blood-tinged sputum, and chest pain. Pneumothorax is incorrect. While the client is experiencing increased respiratory distress, a pneumothorax typically presents with reduced or absent breath sounds and unequal chest expansion.

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 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.

A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect?

Administer an opioid analgesic to the client. The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take?

Administer dextrose 10% in water until the new bag arrives. TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid a precipitous drop in the client's blood glucose level.

A nurse is caring for a client in the emergency department (ED).

Administer morphine Ensure the patient is NPO Cholecystitis Monitor the color of the client's stools Monitor the client for dark urine The nurse should plan to administer an opioid analgesic, such as morphine, for acute pain. Since the client is experiencing nausea and vomiting, the nurse should also ensure they are NPO. The client is likely experiencing cholecystitis, which typically presents with nausea, vomiting, upper abdominal pain that radiates to the right shoulder, fever, and dyspepsia. The client also has elevated liver enzymes and a WBC count, which is consistent with cholecystitis. Surgical management for cholecystitis might be indicated. The nurse should monitor the client's stool and urine color because a biliary obstruction from gallstones may cause clay-colored stools and dark urine.

A nurse is caring for a client who has a migraine. Which of the following interventions should the nurse anticipate? Select all that apply.

Administer sumatriptan Dim the lights in the client's room Administer sumatriptan is correct. The nurse should plan to administer a medication, such as sumatriptan, to produce cerebral artery vasoconstriction and relieve the client's manifestations. Prepare the client for a lumbar puncture is incorrect. A lumbar puncture is indicated for clients who are having manifestations of meningitis. Administer phenobarbital is incorrect. Phenobarbital is indicated for clients who are experiencing seizures. Dim the lights in the client's room is correct. The nurse should plan to dim the lights in the client's room to promote comfort because the client is experiencing photophobia. Prepare to initiate fibrinolytic therapy is incorrect. The nurse should prepare to initiate fibrinolytic therapy for clients who are experiencing a stroke. Fibrinolytic therapy is administered during the acute phase of a stroke to decrease clot formation. Place the client in seizure precautions is incorrect. The nurse should initiate seizure precautions for clients who are at risk for a seizure.

A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid?

Aged cheese Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches.

A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority?

Apply firm pressure to the insertion site. The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding.

A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomyA nurse is providing teaching for the client. Which of the following instructions should the nurse include?

Avoid drinking fluids with meals Eat several small meals per day Consume high-protein snacks Avoid highly seasoned foods Maintain a high carbohydrate intake is incorrect. Dumping syndrome requires a low carbohydrate diet because of reactive hypoglycemia. Eat five servings of fresh fruit per day is incorrect. The client should limit intake to three servings of unsweetened cooked or canned fruit per day. Avoid drinking fluids with meals is correct. The nurse should instruct the client to drink fluids 30 min before or after meals. Eat several small meals per day is correct. The nurse should instruct the client to eat several small, frequent meals instead of three large meals per day. Consume high-protein snacks is correct. The client should eat snacks that are high in protein and low in carbohydrates to prevent the gastric food boluses and reactive hypoglycemia in dumping syndrome. Avoid highly seasoned foods is correct. The nurse should instruct the client to avoid excessive amounts of spices and salt.

A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection?

Avoid placing plants or flowers in the client's room. Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room.

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?

BUN 32 mg/dL DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine.

A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider?

Blood pressure 170/80 mm Hg Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm.

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad?

Bradycardia A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.

A nurse is assessing a male client for an inguinal hernia. Which of the following areas should the nurse palpate to verify that the client has an inguinal hernia? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

C A is incorrect. The nurse should palpate this location to assess the client for a femoral hernia. A femoral hernia is composed of fat and forms in the femoral canal, which, as a result, enlarges and pulls on the peritoneum and sometimes the bladder.B is incorrect. The nurse should palpate this location to assess the client for an umbilical hernia. This type of hernia can be congenital or acquired as a result of pregnancy or obesity and places increased pressure on the abdominal wall.C is correct. The nurse should palpate this location to assess the client for an inguinal hernia. An inguinal hernia forms from the peritoneum, which contains part of the intestine, and can protrude into the scrotum in men.

A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range?

Calcium A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis.

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?

Calcium Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration.

A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer?

Calcium carbonate Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to administer a calcium supplement, such as calcium carbonate, as a calcium replacement.

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. 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 assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take?

Check that one finger fits between the cast and the leg. To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application.

Following the administration of sumatriptan, the nurse should monitor for Select...due to the risk of Select...

Chest pain Myocardial ischemia Dropdown 1 Dehydration is incorrect. Sumatriptan does not cause fluid loss, which could lead to dehydration. Chest pain is correct. The nurse should monitor the client for chest pain because sumatriptan can cause coronary vasospasms. Reflux is incorrect. Reflux is not an adverse effect of sumatriptan. Dropdown 2 Peptic ulcer disease is incorrect. Peptic ulcer disease is not an adverse effect of sumatriptan. Diuresis is incorrect. Fluid loss is not an adverse effect of sumatriptan. Myocardial ischemia is correct. Sumatriptan can cause coronary vasospasms, which can lead to myocardial ischemia.

Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Client is short of breath and has a productive cough with yellow mucus "I could barely breathe when I got up this morning and I had a throbbing headache." Crackles heard in posterior lungs Client is diaphoretic Client is short of breath and has a productive cough with yellow mucus is correct. Shortness of breath, along with a productive cough with yellow mucus, indicates a potential problem. "I could barely breathe when I got up this morning and I had a throbbing headache" is correct. Difficulty breathing and a throbbing headache indicates a potential problem. Crackles heard in posterior lungs is correct. Crackles heard in the posterior lower lobes indicate a potential problem. Capillary refill less than 2 seconds is incorrect. A capillary refill less than 2 seconds is within the expected reference range and indicates adequate perfusion. Client is diaphoretic is correct. Diaphoresis is a manifestation of an elevated temperature or hypoglycemia and indicates a potential problem. Pedal pulses +2 bilaterally is incorrect. Pedal pulses +2 bilaterally is within the expected reference range and indicates adequate perfusion.

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Cough and deep breathe every 2 hr is anticipated. The nurse should anticipate a prescription for coughing and deep breathing to promote lung expansion and improve impaired gas exchange. Obtain a sputum culture and sensitivity is anticipated. The nurse should anticipate a prescription for a sputum culture and sensitivity to determine the type of bacteria present and to identify antibiotics to be prescribed. Perform neurological checks every 2 hr is nonessential. The client is alert and oriented to person, place, and time. Therefore, the nurse does not need to perform neurological checks every 2 hr. Administer oxygen at 3 L/min via nasal cannula is anticipated. The client's oxygen saturation level is 88% on room air, which indicates hypoxemia. Therefore, the nurse should administer oxygen at 3 L/min via nasal cannula. Limit the client's fluid intake to 1,500 mL per day is contraindicated. The client has manifestations of dehydration. Therefore, fluid restriction is contraindicated. Acetaminophen 500 mg PO every 6 hr as needed is anticipated. The nurse should anticipate a prescription for acetaminophen to reduce the client's temperature and promote comfort. Famotidine 40 mg PO daily is nonessential. Famotidine is a histamine2 antagonist that is used in short-term therapy for the treatment of peptic ulcers. Therefore, the nurse does not need to administer famotidine 40 mg PO daily.

A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to the nurse that the client has exophthalmos?

D (부릅 뜬 눈) The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve.

A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take?

Demonstrate ways to deep breathe and cough. The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications.

A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion?

Digoxin Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion.

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 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 reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect?

Elevated bilirubin level Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice.

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?

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

For each finding below, click to specify if the finding is consistent with migraine, stroke, or meningitis. Each finding can support more than one disease process.

Hand grasps is consistent with migraine, stroke, and meningitis. Unilateral weakness can occur due to neurological vascular changes and inflammation that can be present with migraine, 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 can be present. Numbness can also occur with middle cerebral artery strokes. Aphasia is consistent with migraine and stroke. Aphasia can occur due to neurological vascular changes and inflammation that can be present with a migraine and stroke. Visual changes are consistent with migraine, stroke, and meningitis. Visual changes can occur with migraine, stroke, and meningitis due to neurological vascular changes and inflammation that can be present. Family history is consistent with migraine and stroke. Family history is a risk factor associated with migraine and stroke.

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 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 caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider?

Heart rate 55/min The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider.

The nurse is reviewing the client's medical record from Day 5.Click to highlight the findings below that indicate the client is improving. To deselect a finding, click on the finding again.

Heart rate is 72/min Respiratory rate is 20/min Blood pressure is 128/56 mm Hg Oxygen saturation is 95% on room air Heart rate is 72/min is correct. The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. Respiratory rate is 20/min is correct. The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. Blood pressure is 128/56 mm Hg is correct. The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. Oxygen saturation is 95% on room air is correct. The client's oxygen saturation is within the expected reference range and no longer requires supplemental oxygen. Therefore, this finding indicates the client's pulmonary status is improving. Lung sounds are diminished in the bilateral posterior bases with occasional crackles heard upon auscultation is incorrect. The nurse should identify that the client's lungs sounds are still diminished in the bilateral posterior bases with occasional crackles heard upon auscultation due to the client's acute respiratory infection. Therefore, this finding indicates the client's respiratory status is not improving. Cough is productive with yellow mucus is incorrect. The client's cough is still productive with yellow mucus due to the client's acute respiratory infection. Therefore, this finding indicates the client's respiratory status is not improving.

A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider?

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

A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment?

History of asthma A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate.

A nurse is caring for a client has who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis?

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

Hypoactive bowel sounds Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to decreased peristalsis.

A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication?

Hypokalemia Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration.

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. Increasing fluid intake will help to 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 pneumonia. Which of the following assessment findings is the nurse's priority?

Increased respiratory secretions Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. These secretions place the client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the ALS and the pneumonia.

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 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 on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take?

Inject the medication into the anterolateral abdominal wall. The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation.

A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take?

Instruct the client on alternative therapies for pain reduction. The nurse should respect the client's concerns and offer nonpharmacologic alternatives to pain management, such as relaxing activities and distraction.

A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first?

Instruct the client to allow the machine to breathe for them. When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator."

A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take?

Instruct the client to splint the abdomen with a pillow for coughing Plan to ambulate the client as soon as possible Report urinary output to the provider Ask the client to rate their pain on a 0 to 10 pain scale Apply oxygen via a face mask is incorrect. It is not necessary to place a face mask on the client because their SaO2 is within the expected reference range of 95% to 100%. Instruct the client to splint the abdomen with a pillow for coughing is correct. It is important for the client to turn, cough, and deep breathe to reduce the risk for respiratory complications. The nurse should instruct the client to splint the incision while performing these actions to reduce the risk of complications to the surgical incision. Plan to ambulate the client as soon as possible is correct. The nurse should plan to ambulate the client as soon as possible to promote ventilation and decrease the risk of thrombosis. Report urinary output to the provider is correct. The client should produce at least 30 mL of urine per hour. Therefore, the nurse should report this finding to the provider. Ask the client to rate their pain on a 0 to 10 pain scale is correct. The nurse should have the client rate their pain prior to and following the administration of pain medication to evaluate its effectiveness.

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

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

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 hr. The nurse should monitor the temperature of a client who has neutropenia every 4 hr because the client's reduced amount of leukocytes greatly increases the client's risk for infection.

A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew?

Naproxen Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding.

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

Obtain vital signs. The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension 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 caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication?

Orthostatic hypotension The nurse should identify that dilation of arteries and veins causes orthostatic hypotension, which is an adverse effect of enalapril.

The nurse should first address the client's .. followed by the client's..

Oxygen saturation Temperature Dropdown 1 Oxygen saturation is correct. The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to address the client's oxygen saturation. The client's oxygen saturation is 88%, which indicates hypoxemia and requires supplemental oxygen. Loss of appetite is incorrect. The nurse should address the client's loss of appetite, which is a manifestation of an infection. However, there is another finding the nurse should address first. BUN level is incorrect. The nurse should address the client's BUN level because it is elevated. However, there is another finding the nurse should address first. Dropdown 2 Heart rate is incorrect. The nurse should address the client's elevated heart rate, which can result in decreased cardiac output. However, there is another finding the nurse should address first. Temperature is correct. The nurse should next address the client's elevated temperature, which is a manifestation of an infection. The client's elevated temperature can cause an increase in other vital signs, such as heart rate. Headache is incorrect. The nurse should address the client's headache, which is a manifestation of an infection. However, there is another finding the nurse should address first.

The nurse is reviewing the client's diagnostic results. Which of the following findings requires follow-up by the nurse? Select all that apply.

PCO2 level WBC count Chest X-ray Oxygen saturation level BUN level PCO2 level is correct. The client has an elevated PCO2 level, which indicates the retention of carbon dioxide. Therefore, this finding requires follow-up by the nurse. WBC count is correct. The client has an elevated WBC count, which indicates an infection. Therefore, this finding requires follow-up by the nurse. Chest x-ray is correct. The client's chest x-ray indicates increased opacity in the bilateral posterior lobes, which is a manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse. Oxygen saturation level is correct. The client's oxygen saturation is decreased, which is a manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse. Calcium level is incorrect. The client's calcium level is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. HCO3- level is incorrect. The client's HCO3- level is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. BUN level is correct. The client's BUN is elevated, which is a manifestation of dehydration or kidney disease. Therefore, this finding requires follow-up by the nurse.

A nurse is caring for a client who is receiving dialysis treatment.

Perform a 12-lead ECG is not indicated. The client is not reporting chest pain; therefore, a 12-lead ECG is not indicated at this time. Place the client in Trendelenburg position is indicated. The client should be placed in the Trendelenburg position to increase blood flow to the heart, improving cardiac output and organ perfusion. Administer a 0.9% sodium chloride 200 mL IV bolus is indicated. The nurse should administer 200 mL of 0.9% sodium chloride IV bolus to increase fluid volume and the client's blood pressure. Apply oxygen at 2 L/min via nasal cannula is indicated. The nurse should administer oxygen at 2 L/min via nasal cannula to increase the amount of oxygen carried in the blood. Notify the provider immediately is indicated. The nurse should notify the provider immediately as part of the nurse's role to provide an update on the client's condition. Obtain the client's blood glucose level is not indicated. There is no indication that the client is experiencing hypoglycemia; therefore, obtaining a blood glucose level is not indicated.

The client is experiencing manifestations of.. due to..

Peritonitis X-ray results Dropdown 1 Peritonitis is correct. The client is experiencing manifestations of peritonitis, such as abdominal pain, cloudy dialysate, and an elevated white blood cell count. Myxedema coma, hemorrhage, dysrhythmias and pneumonia are incorrect. The client does not exhibit manifestations of any of these conditions based on assessment and laboratory findings. Dropdown 2 X-ray results are correct. The client's abdominal x-ray shows fluid in the abdomen along with inflammation, both of which are indications of peritonitis. Thyroid level, platelet count, potassium level and oxygen saturation are incorrect. These laboratory findings and the oxygen saturation are within the expected reference range and do not indicate peritonitis.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?

Remain with the client for the first 15 min of the infusion. The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood.

A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include?

Remind the client to scan their complete range of vision during ambulation. The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls.

A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?

Report of a night cough 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 assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor?

Respiratory paralysis - The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate. Tachycardia- Magnesium sulfate is used to treat cardiac dysrhythmias, such as torsades de pointes and refractory ventricular fibrillation. Depressed cardiac function, including heart block, is an adverse effect of magnesium sulfate. Increased BP- Magnesium sulfate is used to treat cardiac dysthymias, such as torsades des pointes and refractory ventricular fibrillation. However, magnesium sulfate administration can result in systemic vasodilation and subsequent hypotension. *hyperreflexia- Hyperreflexia is seen in clients who have hypomagnesemia. Depressed or absent reflexes are an adverse effect of magnesium sulfate.

A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include?

Roll each testicle between the thumb and fingers. The nurse should instruct the client to roll each testicle horizontally between the thumbs and fingers to feel for any lumps deep in the center of the testicle.

A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.)

Sleepiness exhibited by the client Widening pulse pressure Decerebrate posturing Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended. A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15 indicates neurological functioning within the expected reference range for eye opening, motor, and verbal response. Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP. Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with concurrent decrease in diastolic blood pressure) is an indication of increased ICP. Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased ICP.

A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect?

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.

A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside?

Suction machine The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client's airway as needed and reduce the risk for aspiration.

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?

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

A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority?

Tachycardia When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately to the provider.

A nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching?

Take daily cranberry supplements. The client should take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI.

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 levels of activity. The nurse should help the client develop realistic goals and activities to have a productive life.

The nurse is reviewing the client's medical record.Select the 3 findings that require nursing intervention.

Temperature WBC count Potassium level Temperature is correct. The nurse should identify that the client continues to have a fever as a result of the body's immune system fighting the infection. Therefore, this finding requires nursing intervention. WBC count is correct. The nurse should identify that the client's WBC count remains elevated, which indicates an infection. Therefore, this finding requires nursing intervention. Heart rate is incorrect. The nurse should identify the client's heart rate is within the expected reference range. Therefore, this finding does not require nursing intervention. Potassium level is correct. The nurse should identify that the client's potassium level is elevated, which places them at risk for cardiac dysrhythmias. Therefore, this finding requires nursing intervention. Oxygen saturation is incorrect. The nurse should identify the client's oxygen saturation has improved and is within the expected reference range. Therefore, this finding does not require nursing intervention.

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 caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing?

Urine output 25 mL/hr Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?

Urine specific gravity 1.045 A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration. *Normal range: 1.010 - 1.020

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?

Use a 30-mL syringe The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.

Select the 4 findings that require follow-up by the nurse.

Virtual disturbances Tingling of the lips Hand grasps Expressive aphasia Visual disturbances is correct. Visual disturbances are manifestations of a neurological event. Therefore, the nurse should follow-up on this finding. Blood pressure is incorrect. The client's blood pressure is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. Tingling of the lips is correct. Tingling in the face is a manifestation of a neurological event. Therefore, the nurse should follow-up on this finding. Orientation is incorrect. The client is alert and orientated x3, which is an expected finding. Therefore, this finding does not require follow-up by the nurse. Hand grasps is correct. The client's hand grasps are unequal, which could indicate a neurological deficit. Therefore, this finding requires follow-up by the nurse. Expressive aphasia is correct. Expressive aphasia is a manifestation of a neurological event. Therefore, the nurse should follow-up on this finding. Pain is incorrect. The client denies pain. Therefore, this finding does not require follow-up by the nurse.

A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care?

Wear a lead apron while providing care to the client. The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure.

A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions?

Wear a mask Bacterial meningitis requires droplet precautions; therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy.

A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include?

Wrap fingers with individual dressings. The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand.