RN218 FINAL

Key features of polycystic kidney disease

- congenital disorder, clusters of fluid filled cysts develop in the nephrons - hereditary caused by a genetic mutation - more common in caucasians 2 forms - autosomal dominant - multiply when pt reaches age 30 - autosomal dominant - present at birth

Nursing interventions for the client with acute glomerulonephritis

- coordinate to conserve energy - consult provider to determine if fluid restiction is needed - administer antibiotics as prescribed - teach relaxation exercises to descreae stress - monitor BP, respiratory status, fluid and electrolytes

Dietary education for the client with GERD

- soft diet for 1 wk following procedure - avoid offending foods - avoid large meals - avoid carbonated beverages - remain upright after eating - avoid eating before bedtime - consume four to six small throughout the day

A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson disease. Which statement would the nurse include as part of this teaching? A. "Allow the client to be as independent as possible with activities." B. "Assist the client with frequent and meticulous oral care." C. "Assess the client's ability to eat and swallow before each meal." E. "Schedule appointments early in the morning to ensure rest in the afternoon."

A. "Allow the client to be as independent as possible with activities."

The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) A. "Apply lotion to the client's dry skin areas." B. "Use a basin with warm water to bathe the patient." C. "For the patient's oral care, use a soft toothbrush." D. "Provide clippers so the patient can trim the fingernails." E. "Bathe with antibacterial and water-based soaps."

A. "Apply lotion to the client's dry skin areas." C. "For the patient's oral care, use a soft toothbrush." D. "Provide clippers so the patient can trim the fingernails."

A nurse prepares to discharge a client who has heart failure. Which questions would the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.) A. "Are your bedroom and bathroom on the first floor?" B. "What social support do you have at home?" C. "Will you be able to afford your oxygen therapy?" D. "What spiritual beliefs may impact your recovery?" E. "Are you able to accurately weigh yourself at home?"

A. "Are your bedroom and bathroom on the first floor?" B. "What social support do you have at home?" D. "What spiritual beliefs may impact your recovery?"

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) A. "Chemo" gloves B. Face mask C. Impervious gown D. N95 respirator E. Shoe covers F. Eye protection

A. "Chemo" gloves B. Face mask C. Impervious gown F. Eye protection

A nurse is assessing a client with peripheral artery disease (PAD). The client states that walking five blocks is possible without pain. What question asked next by the nurse will give the best information? A. "Could you walk further than that a few months ago?" B. "Do you walk mostly uphill, downhill, or on flat surfaces?" C. "Have you ever considered swimming instead of walking?" D. "How much pain medication do you take each day?"

A. "Could you walk further than that a few months ago?"

The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? A. "Diarrhea is expected; that's how your body gets rid of ammonia." B. "You may take antidiarrheal medication to prevent loose stools." C. "Do not take any more of the medication until your stools firm up." D. "We will need to send a stool specimen to the laboratory as soon as possible."

A. "Diarrhea is expected; that's how your body gets rid of ammonia."

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question would the nurse ask? A. "Do you live in a crowded residence?" B. "When was your last tetanus vaccination?" C. "Have you had any viral infections recently?" D. "Have you traveled out of the country in the last month?"

A. "Do you live in a crowded residence?"

The nurse is caring for a client who has Alzheimer disease. The client's wife states, "I am having trouble managing his behaviors at home." Which questions would the nurse ask to assess potential causes of the client's behavior problems? (Select all that apply.) A. "Does your husband bathe and dress himself independently?" B. "Do you weigh your husband each morning around the same time?" C. "Does his behavior become worse around large crowds?" D. "Does your husband eat healthy foods including fruits and vegetables?" E. "Do you have a clock and calendar in the bedroom and kitchen?"

A. "Does your husband bathe and dress himself independently?" C. "Does his behavior become worse around large crowds?" E. "Do you have a clock and calendar in the bedroom and kitchen?"

A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities would the nurse include in the health teaching? (Select all that apply.) A. "Frequently assesses the ergonomics of the equipment being used." B. "Take breaks to stretch fingers and wrists during working hours." C. "Do not participate in activities that require repetitive actions." D. "Take ibuprofen to decrease pain and swelling in wrists." E. "Adjust chair height to allow for good posture."

A. "Frequently assesses the ergonomics of the equipment being used." B. "Take breaks to stretch fingers and wrists during working hours." E. "Adjust chair height to allow for good posture."

The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? A. "Hepatitis C is not spread through casual contact." B. "If you wear a gown and gloves, you will not get this virus." C. "This virus is only transmitted through a fecal specimen." D. "I can give you an update on your brother's status from here."

A. "Hepatitis C is not spread through casual contact."

A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which question(s) would the nurse ask? (Select all that apply.) A. "How much water do you drink every day?" B. "Do you take estrogen replacement therapy?" C. "Does anyone in your family have a history of cystitis?" D. "Are you on steroids or other immune-suppressing drugs?" E. "Do you drink grapefruit juice or orange juice daily?"

A. "How much water do you drink every day?" B. "Do you take estrogen replacement therapy?" D. "Are you on steroids or other immune-suppressing drugs?"

The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply.) A. "How old are you?" B. "Do you work in health care? C. "Are you receiving hemodialysis?" D. "Do you use IV drugs?" E. "Did you receive blood before 1992?" F. "Have you even been in prison or jail?"

A. "How old are you?" B. "Do you work in health care? C. "Are you receiving hemodialysis?" D. "Do you use IV drugs?" E. "Did you receive blood before 1992?" F. "Have you even been in prison or jail?"

A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed? A. "I am glad that these tubes will fall out at home when I finally shower." B. "I should measure the drainage each day to make sure it is less than an ounce (30 mL)." C. "I should be careful how I lie in bed so that I will not kink the tubing." D. "If there is a foul odor from the drainage, I will contact my primary health care provider."

A. "I am glad that these tubes will fall out at home when I finally shower."

After teaching a client who is recovering from a vertebroplasty, the nurse assesses the patient's understanding. Which statement by the client indicates a need for additional teaching? A. "I can drive myself home after the procedure." B. "I will monitor the puncture site for signs of infection." C. "I can start walking tomorrow and increase my activity slowly." D. "I will remove the dressing the day after discharge."

A. "I can drive myself home after the procedure."

A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the best response by the nurse? A. "I can stay if you would you like to talk more about this." B. "You are lucky to have such a devoted daughter." C. "It is normal to feel as though you are a burden." D. "Would you like to meet with the chaplain?"

A. "I can stay if you would you like to talk more about this."

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? A. "I can use a heating pad on my legs if it's set on low." B. "I should not cross my legs when sitting or lying down." C. "I will go out and buy some warm, heavy socks to wear." D. "It's going to be really hard but I will stop smoking."

A. "I can use a heating pad on my legs if it's set on low."

The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." What is the nurse's best response? A. "I see you are still hungry. I will get you some toast." B. "You ate your breakfast 30 minutes ago." C. "It appears you are confused this morning." D. "Your family will be here soon. Let's get you dressed."

A. "I see you are still hungry. I will get you some toast."

The nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed with Alzheimer disease. Which statement by the caregiver indicates a need for further teaching? A. "I will avoid communicating with the client to prevent agitation." B. "I should use simple, short sentences and one-step instructions." C. "I can try to use gestures or pictures to communicate with the client." D. "I will limit the number of choices I provide for the client."

A. "I will avoid communicating with the client to prevent agitation."

After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? A. "I will limit my total intake of fluids." B. "I must avoid drinking alcoholic beverages." C. "I must avoid drinking caffeinated beverages." D. "I shall try to lose about 10% of my body weight."

A. "I will limit my total intake of fluids."

After teaching a client with a high thoracic spinal cord injury, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of how to prevent respiratory problems at home? A. "I'll use my incentive spirometer every 2 hours while I'm awake." B. "I'll drink thinned fluids to prevent choking." C. "I'll take cough medicine to prevent excessive coughing." D. "I'll position myself on my right side so I don't aspirate."

A. "I'll use my incentive spirometer every 2 hours while I'm awake."

A client with multiple sexual partners has been assessed for symptoms of dysuria and green, malodorous vaginal discharge. The nurse administers an injection of ceftriaxone and gives the client a prescription for doxycycline. The client asks why two drugs are needed. What answer by the nurse is best? A. "It is very common to be infected with both gonorrhea and chlamydia." B. "Giving two medications increases the chance of curing the infection." C. "Some people are not affected by the injection and need more medication." D. "This will prevent you from needing a 3-month follow-up test."

A. "It is very common to be infected with both gonorrhea and chlamydia."

The nurse is planning health teaching for a client starting mirabegron for urinary incontinence. What health teaching would the nurse include? (Select all that apply.) A. "Monitor blood tests carefully if you are prescribed warfarin." B. "Avoid crowds and individuals with infection." C. "Report any fever to your primary health care provider." D. "Take your blood pressure frequently at home." E. "Report palpitations or chest soreness that may occur."

A. "Monitor blood tests carefully if you are prescribed warfarin." D. "Take your blood pressure frequently at home."

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which statement(s) would the nurse include in this education? (Select all that apply.) A. "Participate in an exercise program to strengthen back muscles." B. "Purchase a mattress that allows you to adjust the firmness." C. "Wear flat instead of high-heeled shoes to work each day." D. "Keep your weight within 20% of your ideal body weight." E. "Avoid prolonged standing or sitting, including driving."

A. "Participate in an exercise program to strengthen back muscles." C. "Wear flat instead of high-heeled shoes to work each day." E. "Avoid prolonged standing or sitting, including driving."

The nurse is teaching a client how to use a cane after a right surgical fractured fibula repair. What health teaching would the nurse include? A. "Place the cane on your left side." B. "Move the cane and your left leg at the same time." C. "Be sure the cane is parallel to your waist." E. "Use the cane only when your right leg is painful."

A. "Place the cane on your left side."

A nurse cares for a client placed in skeletal traction. The client asks, "What is the primary purpose of this type of traction?" How would the nurse respond? A. "Skeletal traction will assist in realigning your fractured bone." B. "This treatment will prevent future complications and back pain." C. "Traction decreases muscle spasms that occur with a fracture." D. "This type of traction minimizes damage as a result of fracture treatment."

A. "Skeletal traction will assist in realigning your fractured bone."

A nurse teaches a client with polycystic kidney disease (PKD). Which statements would the nurse include in this client's discharge teaching? (Select all that apply.) A. "Take your blood pressure every morning." B. "Weigh yourself at the same time each day." C. "Adjust your diet to prevent diarrhea." D. "Contact your provider if you have visual disturbances." E. "Assess your urine for renal stones."

A. "Take your blood pressure every morning." B. "Weigh yourself at the same time each day." D. "Contact your provider if you have visual disturbances."

A nurse teaches a client about prosthesis care after amputation. Which statements would the nurse include in the health teaching? (Select all that apply.) A. "The device has been custom made specifically for you." B. "Your prosthetic is good for work but not for exercising." C. "A prosthetist will clean your inserts for you each month." D. "Make sure that you wear the correct liners with your prosthetic." E. "I have scheduled a follow-up appointment for you."

A. "The device has been custom made specifically for you." D. "Make sure that you wear the correct liners with your prosthetic." E. "I have scheduled a follow-up appointment for you."

The family of a client who has hepatic encephalopathy asks why the client is restricted to moderate amounts of dietary protein and has to take lactulose. What is an appropriate response by the nurse? A. "These interventions help to reduce the ammonia level." B. "These interventions help to prevent heart failure." C. "These interventions help the client's jaundice improve." D. "These interventions help to prevent nausea and vomiting."

A. "These interventions help to reduce the ammonia level."

A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond? A. "Weight is the best indication that you are gaining or losing fluid." B. "Daily weights will help us make sure that you're eating properly." C. "The hospital requires that all clients be weighed daily." D. "You need to lose weight to decrease the incidence of heart failure."

A. "Weight is the best indication that you are gaining or losing fluid."

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? A. 0.45% normal saline B. 0.9% normal saline C. Dextrose 50% (D50) D. Lactated Ringer's solution

A. 0.45% normal saline

The nurse assesses clients on a medical-surgical unit. Which clients would the nurse identify as at risk for secondary seizures? (Select all that apply.) A. A 26-year-old woman with a left temporal brain tumor B. A 38-year-old male client in an alcohol withdrawal program C. A 42-year-old football player with a traumatic brain injury D. A 66-year-old female client with multiple sclerosis E. A 72-year-old man with chronic obstructive pulmonary disease

A. A 26-year-old woman with a left temporal brain tumor B. A 38-year-old male client in an alcohol withdrawal program C. A 42-year-old football player with a traumatic brain injury

A nurse assesses clients in a cardiac unit. Which client would the nurse identify as being at greatest risk for the development of left-sided heart failure? A. A 36-year-old woman with aortic stenosis B. A 42-year-old man with pulmonary hypertension C. A 59-year-old woman who smokes cigarettes daily D. A 70-year-old man who had a cerebral vascular accident

A. A 36-year-old woman with aortic stenosis

Which of the following is (are) (a) risk factor(s) for gastric cancer? (Select all that apply.) A. Achlorhydria B. Chronic atrophic gastritis C. H. pylori infection D. Iron deficiency anemia E. Pernicious anemia

A. Achlorhydria B. Chronic atrophic gastritis C. H. pylori infection E. Pernicious anemia

A nurse is caring for an older adult receiving multiple packed red blood cell transfusions. Which assessment finding(s) indicate(s) possible transfusion circulatory overload? (Select all that apply.) A. Acute confusion B. Dyspnea C. Depression D. Hypertension E. Bradycardia F. Bounding pulse

A. Acute confusion B. Dyspnea D. Hypertension F. Bounding pulse

A nurse assesses an older adult who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless with an oxygen saturation of 88%. Which action would the nurse take first? A. Administer oxygen via nasal cannula B. Re-position to a semi-Fowler position C. Increase the intravenous flow rate. D. Assess response to pain medication.

A. Administer oxygen via nasal cannula

A client presents to the emergency department in sickle cell disease crisis. What intervention by the nurse takes priority? A. Administer oxygen. B. Initiate pulse oximetry. C. Give pain medication. D. Start an IV line

A. Administer oxygen.

A client is admitted with a large oral tumor. What assessment by the nurse takes priority? A. Airway B. Breathing C. Circulation D. Nutrition

A. Airway

The nurse recalls that the risk factors for acute gastritis include which of the following? (Select all that apply.) A. Alcohol B. Caffeine C. Corticosteroids D. Fruit juice E. Nonsteroidal anti-inflammatory drugs (NSAIDs)

A. Alcohol B. Caffeine C. Corticosteroids E. Nonsteroidal anti-inflammatory drugs (NSAIDs)

The nurse is teaching a client about risk factors for esophageal cancer. Which risk factors would the nurse include? (Select all that apply.) A. Alcohol intake B. Obesity C. Smoking D. Lack of fresh fruits and vegetables E. Untreated GERD F. Use of NSAIDs

A. Alcohol intake B. Obesity C. Smoking D. Lack of fresh fruits and vegetables E. Untreated GERD

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the assistive personnel (AP) for deep vein thrombosis (DVT) prevention? (Select all that apply.) A. Apply compression stockings. B. Assist with ambulation. C. Encourage coughing and deep breathing. D. Offer fluids frequently. E. Teach leg exercises.

A. Apply compression stockings. B. Assist with ambulation. D. Offer fluids frequently.

A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to assistive personnel (AP)? A. Apply water-soluble ointment to nares and lips. B. Periodically turn the oxygen down or off. C. Replaces the oxygen tubing with a different type. D. Turn the client every 2 hours or as needed.

A. Apply water-soluble ointment to nares and lips.

A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What action by the student demonstrates that more teaching is needed? A. Applying suction while inserting the catheter B. Preoxygenating the client prior to suctioning C. Suctioning for a total of three times if needed D. Suctioning for only 10 to 15 seconds each time

A. Applying suction while inserting the catheter

A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) A. Apricots B. Coffee cake C. Milk shake D. Potato soup E. Steamed broccoli

A. Apricots D. Potato soup

The nurse assesses a client who has chronic pancreatitis. What assessment findings would the nurse expect for this client? (Select all that apply.) A. Ascites B. Weight gain C. Steatorrhea D. Jaundice E. Polydipsia F. Polyuria

A. Ascites C. Steatorrhea D. Jaundice E. Polydipsia F. Polyuria

A client receiving chemotherapy has a white blood cell count of 1000/mm3 (1 109/L). What actions by the nurse are most appropriate? (Select all that apply.) A. Assess all mucous membranes every 4 to 8 hours. B. Do not allow the client to eat meat or poultry. C. Listen to lung sounds and monitor for cough. D. Monitor the venous access device appearance hourly. E. Take and record vital signs every 4 to 8 hours. F. Encourage activity the client can tolerate.

A. Assess all mucous membranes every 4 to 8 hours. C. Listen to lung sounds and monitor for cough. D. Monitor the venous access device appearance hourly. E. Take and record vital signs every 4 to 8 hours.

A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below: What action by the nurse is most important? A. Assess blood pressure and pulse. B. Attach the client to a pulse oximeter. C. Have the client rate his or her pain. D. Facilitate urgent radiation therapy.

A. Assess blood pressure and pulse.

The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below: What action by the nurse is best? A. Assess the client's ankle-brachial index. B. Elevate the client's leg above the heart. C. Obtain an ice pack to provide comfort. D. Prepare to teach about heparin sodium.

A. Assess the client's ankle-brachial index.

An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best? A. Assess the client's lung sounds. B. Assign a different AP to the client. C. Report the AP to the manager. D. Request thicker liquids for meals.

A. Assess the client's lung sounds.

A nurse is preparing to administer a packed red blood cell transfusion to an older adult. Understanding age-related changes, what alteration(s) in the usual protocol is (are) necessary for the nurse to implement? (Select all that apply.) A. Assess vital signs at least every 15 minutes. B. Avoid giving other IV fluids. C. Premedicate to prevent transfusion reaction. D. Transfuse smaller bags of blood. E. Transfuse each unit over 8 hours. F. Assess the client for fluid overload.

A. Assess vital signs at least every 15 minutes. B. Avoid giving other IV fluids. F. Assess the client for fluid overload.

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? A. Assessing the IV site and blood return every hour B. Educating the client on side effects C. Monitoring the client D. Providing warm packs for comfort

A. Assessing the IV site and blood return every hour

A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem? A. Assisting the client to pre-plan for this event B. Reassuring the client that alopecia is temporary C. Teaching the client ways to protect the scalp D. Telling the client that there are worse side effects

A. Assisting the client to pre-plan for this event

The nurse is teaching a client about the risk of uncontrolled or untreated the client's gastroesophageal reflux disease (GERD). What complication(s) may occur if the GERD is not successfully managed? (Select all that apply.) A. Asthma B. Laryngitis C. Dental caries D. Cardiac disease E. Cancer

A. Asthma B. Laryngitis C. Dental caries D. Cardiac disease E. Cancer

A nurse assesses a client who is recovering from an open anterior cervical discectomy and fusion. Which complication would alert the nurse to urgently communicate with the primary health care provider? A. Auscultated stridor B. Weak pedal pulses C. Difficulty swallowing D. Inability to shrug shoulders

A. Auscultated stridor

A primary care clinic sees some clients with sexually transmitted infections. Which diseases would the nurse be required to report to the local authority? (Select all that apply.) A. Chlamydia B. Gonorrhea C. Syphilis D. Human immune deficiency virus E. Pelvic inflammatory disease F. Human papilloma virus

A. Chlamydia B. Gonorrhea C. Syphilis D. Human immune deficiency virus

4. A client has pelvic inflammatory disease (PID). What complications does the nurse monitor the client for? (Select all that apply.) A. Chronic pelvic pain B. Infertility C. Ectopic pregnancy D. Tubo-ovarian abscess E. Peri-hepatitis F. Pancreatitis

A. Chronic pelvic pain B. Infertility C. Ectopic pregnancy D. Tubo-ovarian abscess E. Peri-hepatitis

A nurse knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.) A. Coal miner B. Electrician C. Metal worker D. Plumber E. Textile worker

A. Coal miner C. Metal worker D. Plumber E. Textile worker

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) A. Cognition B. Dexterity C. Hydration D. Range of motion E. Vision F. Upper arm range of motion

A. Cognition B. Dexterity D. Range of motion E. Vision F. Upper arm range of motion

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) A. Create a communication system. B. Don't go out in public alone. C. Find hobbies to enjoy at home. D. Try loose-fitting shirts with collars. E. Wear fashionable scarves.

A. Create a communication system. D. Try loose-fitting shirts with collars. E. Wear fashionable scarves.

A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory test results. Which finding would the nurse report to the primary health care provider? A. Creatinine: 2.9 mg/dL (256 mcmol/L) B. Hematocrit: 30% C. Sodium: 146 mEq/L (146 mmol/L) D. White blood cell count: 12,000/mm3 (12 109/L)

A. Creatinine: 2.9 mg/dL (256 mcmol/L)

The nurse working with oncology clients understands that which age-related change increases the older client's susceptibility to infection during chemotherapy? A. Decreased immune function B. Diminished nutritional stores C. Existing cognitive deficits D. Poor physical reserves

A. Decreased immune function

A nurse working with clients diagnosed with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factor(s) should clients be taught to avoid? (Select all that apply.) A. Dehydration B. Exercise C. Extreme stress D. High altitudes E. Pregnancy

A. Dehydration C. Extreme stress D. High altitudes E. Pregnancy

While undergoing radiation treatment for oral cancer, a client develops xerostomia. What collaborative resource does the nurse suggest for this client's care? A. Dentist B. Occupational therapist C. Speech therapist D. Psychiatrist

A. Dentist

A nurse assesses a client who is recovering from an open traditional anterior cervical fusion. Which assessment findings would alert the nursing to a complication from this procedure? (Select all that apply.) A. Difficulty swallowing B. Hoarse voice C. Constipation D. Bradycardia E. Hypertension

A. Difficulty swallowing B. Hoarse voice

A client asks the nurse why she has urinary incontinence. What risk factors would the nurse recall in preparing to respond to the client's question? (Select all that apply.) A. Diuretic therapy B. Anorexia nervosa C. Stroke D. Dementia E. Arthritis F. Parkinson disease

A. Diuretic therapy C. Stroke D. Dementia E. Arthritis F. Parkinson disease

Which statement(s) about blood transfusion compatibilities is (are) correct? (Select all that apply.) A. Donor blood type A can donate to recipient blood type AB. B. Donor blood type B can donate to recipient blood type O. C. Donor blood type AB can donate to anyone. D. Donor blood type O can donate to anyone. E. Donor blood type A can donate to recipient blood type B.

A. Donor blood type A can donate to recipient blood type AB. D. Donor blood type O can donate to anyone.

The nurse is caring for a client diagnosed with probable gastroesophageal reflux disease (GERD). What assessment finding(s) would the nurse expect? (Select all that apply.) A. Dyspepsia B. Regurgitation C. Belching D. Coughing E. Chest discomfort F. Dysphagia

A. Dyspepsia B. Regurgitation C. Belching D. Coughing E. Chest discomfort F. Dysphagia

The nurse is caring for a client who is diagnosed with urinary tract infection (UTI). What common urinary signs and symptoms does the nurse expect? (Select all that apply.) A. Dysuria B. Frequency C. Burning D. Fever E. Chills F. Hematuria

A. Dysuria B. Frequency C. Burning F. Hematuria

The nurse notes that the primary health care provider documented the presence of mucosal erythroplasia in a client. What does the nurse understand that this most likely means for this client? A. Early sign of oral cancer B. Fungal mouth infection C. Inflammation of the gums D. Obvious oral tumor

A. Early sign of oral cancer

The nurse is reviewing laboratory results of a client recently admitted with a diagnosis of acute pancreatitis. Which values would the nurse expect to be elevated? (Select all that apply.) A. Elastase B. Amylase C. Glucose D. Lipase E. Trypsin F. Calcium

A. Elastase B. Amylase C. Glucose D. Lipase E. Trypsin

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) A. Elevate heels off the bed with a pillow. B. Ambulate the client on the first postoperative day. C. Push the client's patient-controlled analgesia button. D. Re-position the client every 2 hours. E. Use pillows to encourage subluxation of the hip.

A. Elevate heels off the bed with a pillow. B. Ambulate the client on the first postoperative day. D. Re-position the client every 2 hours.

The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory findings would the nurse expect for this client? (Select all that apply.) A. Elevated amylase B. Elevated lipase C. Elevated glucose D. Decreased calcium E. Elevated bilirubin F. Elevated leukocyte count

A. Elevated amylase B. Elevated lipase C. Elevated glucose D. Decreased calcium E. Elevated bilirubin F. Elevated leukocyte count

A 24 year-old female has been diagnosed with genital warts. Which action by the nurse is best? A. Encourage the client to complete STI screening. B. Recommend an over-the-counter wart treatment for genital tissue. C. Report the case to the Centers for Infection Control and Prevention (CDC). D. Discuss popular options for contraception.

A. Encourage the client to complete STI screening.

A nurse wants to reduce the risk potential for transmission of chlamydia and gonorrhea with a client diagnosed with both infections. Which items should be included in the client's teaching plan? (Select all that apply.) A. Expedited partner therapy B. Abstinence until therapy is completed C. Use of intrauterine devices D. Proper use of condoms E. Rescreening for infection F. Use of oral contraception

A. Expedited partner therapy B. Abstinence until therapy is completed D. Proper use of condoms E. Rescreening for infection

The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) A. Flexed trunk B. Long, extended steps C. Slow movements D. Uncontrolled drooling E. Tachycardia

A. Flexed trunk C. Slow movements D. Uncontrolled drooling

The nurse is caring for a 60-year-old female client who sustained a thoracic spinal cord injury 10 years ago. For which potential complication will the nurse assess during this client's care? A. Fracture B. Malabsorption C. Delirium D. Anemia

A. Fracture

A client hospitalized with sickle cell disease crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe that the client is drug seeking. When the client requests pain medication, what action by the nurse is best? A. Give the client pain medication if it is time for another dose. B. Instruct the client not to request pain medication too early. C. Request the primary health care provider leave a prescription for a D. placebo. Tell the client that it is too early to have more pain medication.

A. Give the client pain medication if it is time for another dose.

The nurse is preparing to administer a blood transfusion. Which action(s) by the nurse is (are) most appropriate? (Select all that apply.) A. Hang the blood product using normal saline and a filtered tubing set. B. Take a full set of vital signs prior to starting the blood transfusion. C. Tell the client that someone will remain at the bedside for the first 5 minutes. D. Use gloves to start the client's IV if needed and to handle the blood product. E. Verify the client's identity, and checking blood compatibility and expiration time.

A. Hang the blood product using normal saline and a filtered tubing set. B. Take a full set of vital signs prior to starting the blood transfusion. D. Use gloves to start the client's IV if needed and to handle the blood product.

The nurse assesses a client who is experiencing a common migraine without an aura. Which assessment finding(s) would the nurse expect? (Select all that apply.) A. Headache lasting up to 72 hours B. Unilateral and pulsating headache C. Abrupt loss of consciousness D. Acute confusion E. Pain worsens with physical activities F. Photophobia

A. Headache lasting up to 72 hours B. Unilateral and pulsating headache E. Pain worsens with physical activities F. Photophobia

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would the nurse correlate with neurogenic shock? (Select all that apply.) A. Heart rate of 34 beats/min B. Blood pressure of 185/65 mm Hg C. Urine output less than 30 mL/hr D. Decreased level of consciousness E. Increased oxygen saturation

A. Heart rate of 34 beats/min C. Urine output less than 30 mL/hr D. Decreased level of consciousness

A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (Select all that apply.) A. Hematocrit: 32.8% B. Serum sodium: 130 mEq/L (130 mmol/L) C. Serum potassium: 4.0 mEq/L (4.0 mmol/L) D. Serum creatinine: 1.0 mg/dL (88.4 mcmol/L) E. Proteinuria F. Microalbuminuria

A. Hematocrit: 32.8% B. Serum sodium: 130 mEq/L (130 mmol/L) E. Proteinuria F. Microalbuminuria

The nurse is teaching a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? A. History of hepatitis B B. History of kidney disease C. History of cardiac disease D. History of rectal bleeding

A. History of hepatitis B

The nurse is caring for a client in late-stage Alzheimer disease. Which assessment finding(s) will the nurse anticipate? (Select all that apply.) A. Immobile B. Has difficulty driving C. Wandering D. ADL dependent E. Incontinent F. Possible seizures

A. Immobile D. ADL dependent E. Incontinent F. Possible seizures

The nurse is caring for a client who recently sustained a sports injury to his right leg. What nursing interventions are appropriate for this client? (Select all that apply.) A. Immobilize the right leg. B. Apply heat immediately after the injury. C. Use compression to support the leg. D. Obtain an x-ray to detect possible fracture. E. Elevate the right leg to decrease swelling. F. Administer an opioid every 4 to 6 hours.

A. Immobilize the right leg. C. Use compression to support the leg. D. Obtain an x-ray to detect possible fracture. E. Elevate the right leg to decrease swelling.

The nurse is caring for a client who has been diagnosed with cirrhosis. Which laboratory result(s) would the nurse expect for this client? (Select all that apply.) A. Increased serum bilirubin B. Increased lactate dehydrogenase C. Decreased serum albumin D. Increased serum alanine aminotransferase E. Increased aspartate aminotransferase F. Increased serum ammonia

A. Increased serum bilirubin B. Increased lactate dehydrogenase C. Decreased serum albumin D. Increased serum alanine aminotransferase E. Increased aspartate aminotransferase F. Increased serum ammonia

The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.) A. Infection B. GI bleeding C. Irritable bowel syndrome D. Constipation E. Anemia F. Hypovolemia

A. Infection B. GI bleeding D. Constipation F. Hypovolemia

A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures would the nurse share with the client? (Select all that apply.) A. It leads to minimal blood loss. B. It allows for early ambulation. C. It decreases the risk of infection. D. It increases blood supply to tissues. E. It promotes healing.

A. It leads to minimal blood loss. B. It allows for early ambulation. E. It promotes healing.

The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.) A. Jaundice B. Clay-colored stools C. Icterus D. Ascites E. Petechiae F. Dark urine

A. Jaundice B. Clay-colored stools C. Icterus D. Ascites E. Petechiae F. Dark urine

Which practice does the nurse include when teaching a client about proper oral hygiene? A. Perform self-examination of the mouth every week, and report any unusual findings. B. Brush the teeth daily and floss as needed. C. Wear dentures that fit a bit loosely for movement when chewing. D. Use mouthwash with alcohol unless lesions are present.

A. Perform self-examination of the mouth every week, and report any unusual findings.

The nurse assesses a client who has meningitis. Which sign(s) and symptom(s) would the nurse anticipate? (Select all that apply.) A. Photophobia B. Decreased level of consciousness C. Severe headache D. Fever and chills E. Bradycardia

A. Photophobia B. Decreased level of consciousness C. Severe headache D. Fever and chills

A nurse assesses cerebrospinal fluid leaking onto a client's surgical dressing. What actions would the nurse take? (Select all that apply.) A. Place the client in a flat position. B. Monitor vital signs for hypotension. C. Utilize a bedside commode. D. Assess for abdominal distension. E. Report the leak to the surgeon.

A. Place the client in a flat position. E. Report the leak to the surgeon.

A client who had a surgical fractured femur repair reports new-onset shortness of breath and increased respirations. What is the nurse's first action? A. Place the client in a high-Fowler position. B. Document the client's oxygen saturation level. C. Start oxygen therapy at 2 L/min via nasal cannula. D. Contact the primary health care provider.

A. Place the client in a high-Fowler position.

The nurse is reviewing the results of a client's urinalysis. The client has a diagnosis of acute glomerulonephritis. Which urine findings would the nurse expect? (Select all that apply.) A. Presence of protein B. Presence of red blood cells C. Presence of white blood cells D. Acidic urine E. Dilute urine

A. Presence of protein C. Presence of white blood cells D. Acidic urine

A nurse assesses a client with nephrotic syndrome. Which assessment findings would the nurse expect? (Select all that apply.) A. Proteinuria B. Hypoalbuminemia C. Dehydration D. Lipiduria E. Dysuria F. Costovertebral angle (CVA) tenderness

A. Proteinuria B. Hypoalbuminemia D. Lipiduria

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (Select all that apply. A. Pulmonary crackles B. Confusion C. Pulmonary hypertension D. Dependent edema E. Cough that worsens at night F. Jugular venous distention

A. Pulmonary crackles B. Confusion E. Cough that worsens at night

A client being treated for syphilis visits the office with a possible allergic reaction to benzathine penicillin G. Which abnormal findings would the nurse expect to document? (Select all that apply.) A. Red rash B. Shortness of breath C. Heart irregularity D. Chest tightness E. Anxiety F. Confusion

A. Red rash B. Shortness of breath D. Chest tightness E. Anxiety

The nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members would the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) A. Registered dietitian nutritionist B. Nursing assistant C. Clinical pharmacist D. Certified herbalist E. Primary health care provider

A. Registered dietitian nutritionist C. Clinical pharmacist E. Primary health care provider

A nurse is caring for a client with diabetes mellitus who has fractured her arm. Which action would the nurse take first? A. Remove the medical alert bracelet from the fractured arm. B. Immobilize the arm by splinting the fractured site. C. Place the client in a supine position with a warm blanket. D. Cover any open areas with a sterile dressing.

A. Remove the medical alert bracelet from the fractured arm.

A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern? A. Request a prescription for an antispasmodic drug such as baclofen. B. Prepare the client for deep brain stimulation surgery. C. Refer the client to a massage therapist to relax the muscles. D. Consult with the occupational therapist for self-care assistance.

A. Request a prescription for an antispasmodic drug such as baclofen.

A client is admitted to the emergency department with possible acute pancreatitis. What is the nurse's priority assessment at this time? A. Respiratory assessment B. Cardiovascular assessment C. Abdominal assessment D. Pain intensity assessment

A. Respiratory assessment

When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (Select all that apply.) A. Right upper quadrant tenderness B. Itching C. Recent influenza infection D. Brown stool E. Tea-colored urine

A. Right upper quadrant tenderness B. Itching E. Tea-colored urine

The nurse is taking a history of an older adult. Which factors would the nurse assess as potential risks for low back pain? (Select all that apply.) A. Scoliosis B. Spinal stenosis C. Hypocalcemia D. Osteoporosis E. Osteoarthritis

A. Scoliosis B. Spinal stenosis C. Hypocalcemia D. Osteoporosis E. Osteoarthritis

A client is placed on a medical regimen of doxorubicin (Adriamycin), cyclophosphamide, and fluorouracil for breast cancer. Which side effect seen in the client would the nurse report to the primary health care provider immediately? A. Shortness of breath B. Nausea and vomiting C. Hair loss D. Mucositis

A. Shortness of breath

The nurse teaches the client who has cirrhosis about foods and other substances that should be avoided to prevent worsening of the disease. Which substance(s) will the nurse include in that health teaching? (Select all that apply.) A. Smoking B. Alcohol C. Illicit drugs D. Acetaminophen E. Sodium F. Protein

A. Smoking B. Alcohol C. Illicit drugs D. Acetaminophen

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data would the nurse obtain to assess the client's coping strategies? (Select all that apply.) A. Spiritual beliefs B. Level of pain C. Family support D. Level of independence E. Annual income F. Previous coping strategies

A. Spiritual beliefs C. Family support D. Level of independence F. Previous coping strategies

A nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use? A. Standard Precautions B. Bleeding Precautions C. Reverse isolation D. Contact isolation

A. Standard Precautions

A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their description? (Select all that apply.) A. Stress incontinence—urine loss with physical exertion B. Urge incontinence—loss of urine upon feeling the need to void C. Functional incontinence—urine loss results from abnormal detrusor contractions D. Overflow incontinence—constant dribbling of urine E. Reflex incontinence—leakage of urine without lower urinary tract disorder

A. Stress incontinence—urine loss with physical exertion B. Urge incontinence—loss of urine upon feeling the need to void D. Overflow incontinence—constant dribbling of urine

Which assessment finding(s) may indicate that a client may be experiencing a blood transfusion reaction? (Select all that apply.) A. Tachycardia B. Fever C. Bronchospasm D. Tachypnea E. Urticaria F. Hypotension

A. Tachycardia B. Fever C. Bronchospasm D. Tachypnea E. Urticaria F. Hypotension

A nurse evaluates a client with acute glomerulonephritis (GN). Which assessment finding would the nurse recognize as a positive response to the prescribed treatment? A. The client lost 11 lb (5 kg) in the past 10 days. B. The client's urine specific gravity is 1.048. C. No blood is observed in the client's urine. D. The client's blood pressure is 152/88 mm Hg.

A. The client lost 11 lb (5 kg) in the past 10 days.

The nurse is caring for a client receiving a unit of whole blood. Which nursing action(s) is (are) appropriate regarding infusion administration. (Select all that apply.) A. Use a dedicated filtered blood administration set. B. Stay with the client for the first 15 to 20 minutes of the infusion. C. Infuse the blood over a 30-minute period of time. D. Monitor and document vital signs per agency policy. E. Use a 21-gauge or smaller catheter to administer the blood. F. Infuse the transfusion with intravenous normal saline.

A. Use a dedicated filtered blood administration set. B. Stay with the client for the first 15 to 20 minutes of the infusion. D. Monitor and document vital signs per agency policy. F. Infuse the transfusion with intravenous normal saline.

After treating several young women for urinary tract infections (UTIs), the college nurse plans an educational offering on reducing the risk of getting a UTI. What information does the nurse include? (Select all that apply.) A. Void before and after each act of intercourse. B. Consider changing to spermicide from birth control pills. C. Do not douche or use scented feminine products. D. Wear loose-fitting nylon panties. E. Wipe or clean the perineum from front to back.

A. Void before and after each act of intercourse. C. Do not douche or use scented feminine products. E. Wipe or clean the perineum from front to back.

The nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) A.Have suction equipment with an airway at the bedside. B. Place a padded tongue blade at the bedside. C. Permit only clear oral fluids. D. Have oxygen administration set at the bedside. E. Maintain the client on strict bedrest. F. Ensure that the client has IV access.

A.Have suction equipment with an airway at the bedside. D. Have oxygen administration set at the bedside. F. Ensure that the client has IV access.

Automatisms and the client is unaware of his or her environment.

Absence seizures

Sudden loss of muscle tone followed by postictal confusion

Atonic seizure

A college student seeks information from the school's nurse about how to avoid sexually transmitted infections (STIs) without abstinence as a choice. Which statement by the nurse is best? A. "Urinating after intercourse will eliminate the risk of infection." B. "A vaccine can prevent genital warts caused by some strains of the human papilloma virus (HPV)." C. "Oral contraception can prevent pregnancy and STIs." D. "Good handwashing helps prevent infection associated with STIs."

B. "A vaccine can prevent genital warts caused by some strains of the human papilloma virus (HPV)."

A male client is diagnosed with primary syphilis. Which question by the nurse is a priority at this time? A. "Have you been using latex condoms?" B. "Are you allergic to penicillin?" C. "When was your last sexual encounter?" D. "Do you have a history of sexually transmitted infections?"

B. "Are you allergic to penicillin?" Benzathine penicillin G is the evidence-based treatment for primary, secondary, and early latent syphilis.

A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure? A. "Do you have trouble breathing or chest pain?" B. "Are you still able to walk upstairs without fatigue?" C. "Do you awake with breathlessness during the night?" D. "Do you have new-onset heaviness in your legs?"

B. "Are you still able to walk upstairs without fatigue?"

The nurse is teaching a client diagnosed with gastroesophageal reflux disease (GERD) who is planning to have an endoscopic radiofrequency (Stretta) procedure. What preprocedure health teaching would the nurse include? (Select all that apply.) A. "You will need to be on a liquid diet for the first week after the procedure." B. "Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure." C. "Contact the primary health care provider after the procedure if you have increased pain." D. "You will need a nasogastric tube for a few days after the procedure." E. "You will have a small incision in your stomach area that will have a wound closure.

B. "Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure." C. "Contact the primary health care provider after the procedure if you have increased pain."

A client is concerned about the risk of lymphedema after a mastectomy. Which response by the nurse is best? A. "You do not need to worry about lymphedema since you did not have radiation therapy." B. "Be careful not to injure that arm or get any infection in that arm." C. "Numbness, tingling, and swelling are common sensations after a mastectomy." D. "The risk for lymphedema is a real threat and can be very self-limiting."

B. "Be careful not to injure that arm or get any infection in that arm."

A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching? A. "Walk until you become short of breath, and then walk back home." B. "Begin walking 200 feet a day three times a week." C. "Do not lift heavy weights for 6 months." D. "Eat plenty of protein to build your strength."

B. "Begin walking 200 feet a day three times a week."

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? A. "Avoid getting salt water on the radiation site." B. "Do not expose the radiation area to direct sunlight." C. "Have a wonderful time and enjoy your vacation!" D. "Remember you should not drink alcohol for a year."

B. "Do not expose the radiation area to direct sunlight."

The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client's caregiver states, "She is always wandering off. What can I do to manage this restless behavior?" What is the nurse's best response? A. "This is a sign of fatigue. The client would benefit from a daily nap." B. "Engage the client in scheduled activities throughout the day." C. "It sounds like this is difficult for you. I will consult the social worker." D. "The provider can prescribe a mild sedative for restlessness."

B. "Engage the client in scheduled activities throughout the day."

A nurse assesses the health history of a client who is prescribed ziconotide for chronic low back pain. Which assessment question would the nurse ask? A. "Are you taking a nonsteroidal anti-inflammatory drug?" B. "Have you been diagnosed with a mental health problem?" C. "Are you able to swallow oral medications?" D. "Do you smoke cigarettes or any illegal drugs?"

B. "Have you been diagnosed with a mental health problem?"

After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? A. "I will take a laxative every night before going to bed." B. "I must increase my intake of dietary fiber and fluids." C. "I shall only use salt when I am cooking my own food." D. "I'll eat white bread to minimize gastrointestinal gas."

B. "I must increase my intake of dietary fiber and fluids."

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching? A. "I'll be able to carry heavy loads after 6 months of rest." B. "I will have my teeth cleaned by my dentist in 2 weeks." C. "I must avoid eating foods high in vitamin K, like spinach." D. "I must use an electric razor instead of a straight razor to shave."

B. "I will have my teeth cleaned by my dentist in 2 weeks."

A client is scheduled for a percutaneous endoscopic lumbar discectomy. Which statement by the client indicates a need for further teaching? A. "I should have a lot less pain after surgery." B. "I'll be in the hospital for 2 to 3 days." C. "I should not have any major surgical complications." D. "I could possibly get an infection after surgery."

B. "I'll be in the hospital for 2 to 3 days."

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate? A. "Are you getting adequate rest and sleep each day?" B. "It is normal to be fatigued even for months afterward." C. "This is not normal and I'll let the primary health care provider know." D. "Try adding more vitamins B and C to your diet."

B. "It is normal to be fatigued even for months afterward."

A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, "I never have urinary tract infections. Why is this happening now?" How would the nurse respond? A. "Your immune system becomes less effective as you age." B. "Low estrogen levels can make the tissue more susceptible to infection." C. "You should be more careful with your personal hygiene in this area." D. "It is likely that you have an untreated sexually transmitted disease."

B. "Low estrogen levels can make the tissue more susceptible to infection."

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A. "The scars on my liver create problems with blood circulation." B. "My liver is scarred, but the cells can regenerate themselves and repair the damage." C. "Because of the scars on my liver, blood clotting and blood pressure are affected." D. "Cirrhosis is a chronic disease that has scarred my liver."

B. "My liver is scarred, but the cells can regenerate themselves and repair the damage."

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? A. "I sleep with four pillows at night." B. "My shoes fit really tight lately." C. "I wake up coughing every night." D. "I have trouble catching my breath."

B. "My shoes fit really tight lately."

A client has an external percutaneous transhepatic biliary catheter inserted for a biliary obstruction. What health teaching about catheter care would the nurse provide for the client? A. "Cap the catheter drain at night to prevent leakage and skin damage." B. "Position the drainage bag lower than the catheter insertion site." C. "Irrigate the catheter with an ounce of saline every night." D. "Pierce a hole in the top of the drainage bag to get rid of odors."

B. "Position the drainage bag lower than the catheter insertion site."

A nurse is teaching a client who experiences migraine headaches and is prescribed propranolol. Which statement would the nurse include in this client's teaching? A. "Take this drug only when you have symptoms indicating the onset of a migraine headache." B. "Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches." C. "This drug will relieve the pain during the aura phase soon after a headache has started." D. "This drug will have no effect on your heart rate or blood pressure because you are taking it for migraines."

B. "Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches."

A nurse teaches a client who is recovering from an open traditional cervical spinal fusion. Which statement would the nurse include in this client's postoperative instructions? A. "Only lift items that are 10 lb (4.5 kg) or less." B. "Wear your neck brace whenever you are out of bed." C. "You must remain in bed for 3 weeks after surgery." D. "You will be prescribed medications to prevent graft rejection."

B. "Wear your neck brace whenever you are out of bed."

The nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question would the nurse ask first? A. "Are you drinking plenty of water?" B. "What medications are you taking?" C. "Have you tried laxatives or enemas?" D. "Has this type of thing ever happened before?"

B. "What medications are you taking?"

A client who had a traumatic above-the-knee amputation states that he fears he will never have an intimate relationship again. What is the nurse's best response? A. "You'll be able to get a leg prosthesis soon." B. "You think you won't be able to have sex again?" C. "I will ask the social worker to talk with you." D. "Are you married now or have a girl friend?"

B. "You think you won't be able to have sex again?"

A nurse caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? A. 14% B. 21% C. 28% D. 31%

B. 21%

A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify as being at greatest risk for atrial fibrillation? A. A 45-year-old who takes an aspirin daily. B. A 50-year-old who is post coronary artery bypass graft surgery. C. A 78-year-old who had a carotid endarterectomy. D. An 80-year-old with chronic obstructive pulmonary disease.

B. A 50-year-old who is post coronary artery bypass graft surgery.

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A. Assist the client to assume a position of comfort. B. Administer opioid analgesic medication. C. Do not administer food or fluids by mouth. D. Measure intake and output every shift.

B. Administer opioid analgesic medication.

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the assistive personnel (AP)? A. Ambulate the client. B. Apply a warm moist pack. C. Massage the client's leg. D. Provide an ice pack.

B. Apply a warm moist pack.

The nurse is caring for a client who just had a kyphoplasty. What nursing care is needed for the client at this time? (Select all that apply.) A. Place the client in a prone position to prevent pressure on the surgical area. B. Apply an ice pack to the surgical area to help relieve pain. C. Assess the client's pain level to compare it with pain before the procedure. D. Take vital signs, including oxygen saturation, frequently. E. Monitor for complications such as bleeding or shortness of breath. F. Perform frequent neurologic assessments and report major changes.

B. Apply an ice pack to the surgical area to help relieve pain. C. Assess the client's pain level to compare it with pain before the procedure. D. Take vital signs, including oxygen saturation, frequently. E. Monitor for complications such as bleeding or shortness of breath. F. Perform frequent neurologic assessments and report major changes.

A client is admitted to the emergency department with a fractured femur resulting from a motor vehicle crash. What the nurse's priority action? A. Keep the client warm and comfortable. B. Assess airway, breathing, and circulation. C. Maintain the client in a supine position. D. Immobilize the injured extremity with a splint.

B. Assess airway, breathing, and circulation.

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) A. Administer pain medication. B. Assess distal pulses every 10 minutes. C. Have the client sign a surgical consent. D. Notify the Rapid Response Team. E. Take vital signs every 10 minutes.

B. Assess distal pulses every 10 minutes. D. Notify the Rapid Response Team. E. Take vital signs every 10 minutes.

A nurse plans care for a client with a halo fixator. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) A. Remove the vest for client bathing. B. Assess the pin sites for signs of infection. C. Loosen the pins when sleeping. D. Decrease the patient's oral fluid intake. E. Assess the chest and back for skin breakdown.

B. Assess the pin sites for signs of infection. E. Assess the chest and back for skin breakdown.

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. What action would the nurse take next? A. Administer intravenous diltiazem. B. Assess vital signs and level of consciousness. C. Administer sublingual nitroglycerin. D. Assess capillary refill and temperature.

B. Assess vital signs and level of consciousness.

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? A. Allow the client to rest. B. Auscultate lung sounds. C. Document the episode. D. Encourage the client to eat dry toast.

B. Auscultate lung sounds.

After delegating care to assistive personnel (AP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the AP's understanding. Which action indicates that the AP needs additional teaching? A. Toileting the client after breakfast B. Changing the client's incontinence brief when wet C. Encouraging the client to drink fluids D. Recording the client's incontinence episodes

B. Changing the client's incontinence brief when wet

The nurse and the registered dietitian nutritionist are planning sample diet menus for a client who is experiencing dumping syndrome. Which sample meal is most appropriate for this client? A. Liver, bacon, and onions B. Chicken and white rice C. Chicken salad on whole wheat bread D. Green vegetable salad with buttermilk ranch dressing

B. Chicken and white rice

A nurse participates in a community screening event for oral cancer. What client is the highest priority for referral to a primary health care provider? A. Client who has poor oral hygiene practices. B. Client who smokes and drinks daily. C. Client who tans for an D. Client who occasionally uses illicit drugs.

B. Client who smokes and drinks daily.

A client who had a fractured ankle open reduction internal fixation (ORIF) 4 weeks ago reports burning pain and tingling in the affected foot. For which potential complication would the nurse anticipate? A. Delayed bone healing B. Complex regional pain syndrome C. Peripheral neuropathy D. Compartment syndrome

B. Complex regional pain syndrome

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? A. Call the primary health care provider to request more analgesia. B. Demonstrate how to splint the incision. C. Have the client take shallower breaths. D. Tell the client that a little pain is expected.

B. Demonstrate how to splint the incision.

A client presents to the emergency department with a thoracic aortic aneurysm. Which findings are most consistent with this condition? (Select all that apply.) A. Abdominal tenderness B. Difficulty swallowing C. Changes in bowel habits D. Shortness of breath E. Hoarseness

B. Difficulty swallowing D. Shortness of breath E. Hoarseness

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? A. Answer the questions and document that teaching was done. B. Do not have the client sign the consent and call the primary health care provider. C. Have the client sign the consent, and then call the primary health care provider. D. Remind the client of what teaching the primary health care provider has done.

B. Do not have the client sign the consent and call the primary health care provider.

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? A. Document the events in the client's medical record. B. Double-check the client and blood product identification. C. Place the client on strict bedrest until the pain subsides. D. Review the client's medical record for known allergies.

B. Double-check the client and blood product identification.

A client who had a partial gastrectomy 3 days ago begins to experience vertigo, sweating, and tachycardia about 30 minutes after eating breakfast. What postoperative complication would the nurse suspect? A. Pyloric obstruction B. Dumping syndrome C. Delayed gastric emptying D. Pernicious anemia

B. Dumping syndrome

A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder? (Select all that apply.) A. Elevated aspartate transaminase B. Elevated international normalized ratio (INR) C. Decreased serum globulin levels D. Decreased serum alkaline phosphatase E. Elevated serum ammonia F. Elevated prothrombin time (PT)

B. Elevated international normalized ratio (INR) E. Elevated serum ammonia F. Elevated prothrombin time (PT)

A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention would the nurse include in this client's plan of care? A. Place pillows between the client's knees. B. Encourage range-of-motion exercises. C. Administer prophylactic antibiotics. D. Implement strict bedrest in a supine position.

B. Encourage range-of-motion exercises.

A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which nursing action is most appropriate to manage this client's dementia? A. Provide animal-assisted therapy as needed. B. Ensure a structured and consistent environment. C. Assist the client with activities of daily living (ADLs). D. Use validation therapy when communicating with the client.

B. Ensure a structured and consistent environment.

A nurse is preparing to administer a blood transfusion. What action is most important? A. Correctly identify client using two identifiers. B. Ensure that informed consent is obtained. C. Hang the blood product with Ringer's lactate. D. Stay with the client for the entire transfusion.

B. Ensure that informed consent is obtained.

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? A. Administer prescribed anxiolytic medication. B. Ensure that informed consent is on the chart. C. Reinforce any teaching done previously. D. Start the preoperative antibiotic infusion.

B. Ensure that informed consent is on the chart.

A nurse prepares to discharge a client who has heart failure. Based on national quality measures, what actions would the nurse complete prior to discharging this client? (Select all that apply.) A. Teach the client about energy conservation techniques. B. Ensure that the client is prescribed a beta blocker. C. Document a discussion about advanced directives. D. Confirm that a postdischarge nurse visit has been scheduled. E. Consult a social worker for additional resources. F.Care transition record transmitted to next level of care within 7 days of discharge.

B. Ensure that the client is prescribed a beta blocker. C. Document a discussion about advanced directives. D. Confirm that a postdischarge nurse visit has been scheduled. F.Care transition record transmitted to next level of care within 7 days of discharge.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod. For which common side effect would the nurse monitor? A. Peripheral edema B. Facial flushing C. Tachycardia D. Fever

B. Facial flushing

A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury. What other assessment finding will the nurse anticipate for this client? A. Quadriplegia B. Flaccid bowel C. Spastic bladder D. Tetraparesis

B. Flaccid bowel

A nurse assesses a client who has a family history of polycystic kidney disease (PKD). Which assessment findings would the nurse expect? (Select all that apply.) A. Nocturia B. Flank pain C. Increased abdominal girth D. Dysuria E. Hematuria F. Diarrhea

B. Flank pain C. Increased abdominal girth E. Hematuria

The nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate for migraine headaches. Which condition would alert the nurse to withhold the medication and contact the primary health care provider? A. Bronchial asthma B. Heart disease C. Diabetes mellitus D. Rheumatoid arthritis

B. Heart disease

After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is most important for the nurse to implement? A. Provide food to decrease nausea and aid in absorption. B. Instruct the client to ask for assistance when rising from bed. C. Collaborate with assistive personnel to bathe the client. D. Monitor potassium levels and check for symptoms of hypokalemia.

B. Instruct the client to ask for assistance when rising from bed.

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met? A. 100% of meals being eaten by the client B. Intact skin behind the ears C. The client understanding the need for oxygen D. Unchanged weight for the past 3 days

B. Intact skin behind the ears

A client with oral cancer who is to have a radical neck dissection reports being depressed. What is the nurse's priority response? A. Suggest seeking support from a community group. B. Listen to the client's concerns. C. Explain the grieving process. D. Reassure that it is normal to feel depressed about the diagnosis.

B. Listen to the client's concerns.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse anticipate to prepare for administration? A. Atenolol B. Lorazepam C. Phenytoin D. Lisinopril

B. Lorazepam

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? A. Elevate the head of the client's bed. B. Measure and compare cuff pressures. C. Place the client on NPO status. D. Request that the client have a swallow study.

B. Measure and compare cuff pressures.

A nurse reviews the laboratory findings of a client with a urinary tract infection (bacterial cystitis). The laboratory report notes a "shift to the left" in the client's white blood cell count. What action would the nurse take? A. Request that the laboratory perform a differential analysis on the white blood cells. B. Notify the primary health care provider and start an intravenous line for parenteral antibiotics. C. Ask assistive personnel (AP) to strain the client's urine for renal calculi. D. Assess the client for a potential allergic reaction and anaphylactic shock.

B. Notify the primary health care provider and start an intravenous line for parenteral antibiotics.

A nurse cares for a client with a recently fractured tibia. Which assessment would alert the nurse to take immediate action? A. Pain of 4 on a scale of 0-10 B. Numbness in the extremity C. Swollen extremity at the injury site D. Feeling cold while lying in bed

B. Numbness in the extremity

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met? A. Ambulates with assistance B. Oxygen saturation of 98% C. Pain of 2/10 after medication D. Verbalizing risk factors

B. Oxygen saturation of 98%

A client has a nasogastric (NG) tube as a result of an upper gastrointestinal (GI) hemorrhage. What comfort measure would the nurse remind assistive personnel (AP) to provide? A. Lavaging the tube with ice water B. Performing frequent oral care C. Re-positioning the tube every 4 hours D. Taking and recording vital signs

B. Performing frequent oral care

A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding would alert the nurse to immediately contact the primary health care provider? A. Flank pain B. Periorbital edema C. Bloody and cloudy urine D. Enlarged abdomen

B. Periorbital edema

The nurse is caring for a client diagnosed with oral cancer. What is the nurse's priority for client care? A. Encourage fluids to liquefy the client's secretions. B. Place the client on Aspiration Precautions. C. Remind the client to use an incentive spirometer. D. Manage the client's pain and inflammation.

B. Place the client on Aspiration Precautions.

The nurse is assessing a client who has hepatitis C. What extrahepatic complications would the nurse anticipate? (Select all that apply.) A. Pancreatitis B. Polyarthritis C. Heart disease D. Myalgia E. Peptic ulcer disease F. Ulcerative colitis

B. Polyarthritis C. Heart disease D. Myalgia

The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? A. Monitor intake and output. B. Provide a low-sodium diet. C. Increase oral fluid intake. D. Weigh the patient daily.

B. Provide a low-sodium diet.

A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? A. Nausea and vomiting B. Severe boring abdominal pain C. Jaundice and itching D. Elevated temperature

B. Severe boring abdominal painQ

A nurse assesses a client with atrial fibrillation. Which manifestation would alert the nurse to the possibility of a serious complication from this condition? A. Sinus tachycardia B. Speech alterations C. Fatigue D. Dyspnea with activity

B. Speech alterations

When caring for a client with Laennec cirrhosis, which of these findings does the nurse expect to find on assessment? (Select all that apply.) A. Elevated magnesium B. Swollen abdomen C. Prolonged partial thromboplastin time D. Elevated amylase level E. Currant jelly stool F. Icterus of skin

B. Swollen abdomen C. Prolonged partial thromboplastin time F. Icterus of skin

Which teaching point is most important for the client with a peritonsillar abscess? A. Gargle with warm salt water. B. Take all antibiotics as directed. C. Let us know if you want liquid medications. D. Wash hands frequently.

B. Take all antibiotics as directed.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the client's decrease in self-esteem are being met? A. The client demonstrates good understanding of stoma care. B. The client has joined a book club that meets at the library. C. Family members take turns assisting with stoma care. D. Skin around the stoma is intact without signs of infection.

B. The client has joined a book club that meets at the library.

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. What action would the nurse take prior to the cardioversion? A. Administer intravenous adenosine. B. Turn off oxygen therapy. C. Ensure that a tongue blade is available. D. Position the client on the left side.

B. Turn off oxygen therapy.

The nurse assesses a client who is admitted with a pelvic fracture. Which assessments would the nurse monitor to prevent or detect a complication of this injury? (Select all that apply.) A. Temperature B. Urinary output C. Blood pressure D. Pupil reaction E. Skin color

B. Urinary output C. Blood pressure E. Skin color

A client who has undergone surgery and completed radiation therapy to treat oral cancer reports persistent dry mouth. What will the nurse teach this client about managing this symptom? A. This condition is common but is temporary. B. Use saliva substitutes, especially when eating dry foods. C. This indicates a complication of therapy. D. Use lozenges and hard candies to prevent dry mouth.

B. Use saliva substitutes, especially when eating dry foods.

5. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication would the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? A. Sotalol B. Warfarin C. Atropine D. Lidocaine

B. Warfarin

After teaching a client with bacterial cystitis who is prescribed phenazopyridine, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? A. "I will not take this drug with food or milk." B. "I will have my partners tested for STIs." C. "An orange color in my urine should not alarm me." D. "I will drink two glasses of cranberry juice daily."

C. "An orange color in my urine should not alarm me."

A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client's discharge teaching? A. "Be sure that you use a wheelchair when you go out in public." B. "Wear an undergarment brief at all times in case of incontinence." C. "Avoid overexertion, stress, and extreme temperature if possible." D. "Avoid having sexual intercourse to conserve energy."

C. "Avoid overexertion, stress, and extreme temperature if possible."

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses his understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of his injury? (Select all that apply.) A. "I will explore other ways besides intercourse to please my partner." B. "I will not be able to have an erection because of my injury." C. "Ejaculation may not be as predictable as before." D. "I may urinate with ejaculation but this will not cause infection." E. "I should be able to have an erection with stimulation."

C. "Ejaculation may not be as predictable as before." D. "I may urinate with ejaculation but this will not cause infection." E. "I should be able to have an erection with stimulation."

The nurse is teaching a client about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the client indicates a need for further teaching? A. "I cannot drink alcohol at all." B. "I will need to avoid sweetened fruit juice beverages." C. "I can eat ice cream in moderation." D. "It is okay to have a serving of sugar-free pudding."

C. "I can eat ice cream in moderation." Milk products such as ice cream must be eliminated from the diet of a patient with dumping syndrome.

The nurse is caring for a client with urinary incontinence. The client states, "I am so embarrassed. My bladder leaks like a young child's bladder." How would the nurse respond? A. "I understand how you feel. I would be mortified." B. "Incontinence pads will minimize leaks in public." C. "I can teach you strategies to help control your incontinence." D. "More people experience incontinence than you might think."

C. "I can teach you strategies to help control your incontinence."

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? A. "I have been drinking more water than usual." B. "I am awakened by the need to urinate at night." C. "I must stop halfway up the stairs to catch my breath." D. "I have experienced blurred vision on several occasions."

C. "I must stop halfway up the stairs to catch my breath."

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? A. "I cannot drink any alcohol at all anymore." B. "I should not take over-the-counter medications." C. "I need to avoid protein in my diet." D. "I should eat small, frequent, balanced meals."

C. "I need to avoid protein in my diet."

A female client returned to the clinic with a yellow vaginal discharge after being treated for Chlamydia infection 3 weeks ago. Which statement by the client alerts the nurse that there may be a recurrence of the infection? A. "I did practice abstinence while taking the medication." B. "I took doxycycline two times a day for a week." C. "I never told my boyfriend about the infection." E. "I did drink wine when taking the medication for Chlamydia."

C. "I never told my boyfriend about the infection."

The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking glatiramer acetate. Which statement by the client indicates a need for further teaching? A. "I will rotate injection sites to prevent skin irritation." B. "I need to avoid large crowds and people with infection." C. "I should report any flu like symptoms to my primary health care provider." D. "I will report any signs of infection to my primary health care provider."

C. "I should report any flu like symptoms to my primary health care provider."

The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? A. "You should make peace with your family." B. "This is not unusual. My family hates me too." C. "I will help you identify a support system." D. "You must attend Alcoholics Anonymous."

C. "I will help you identify a support system."

The nurse is teaching a client diagnosed with stomatitis about special mouth care. Which statement by the client indicates a need for further teaching? A. "I need to take out my dentures until my mouth heals." B. "I'll try to eat soft foods that aren't spicy and acidic." C. "I will use a more firm toothbrush to keep my mouth clean." D. "I'll be sure to rinse my mouth often with warm salt water."

C. "I will use a more firm toothbrush to keep my mouth clean."

The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The daughter asks, "Will the sertraline my mother is taking improve her dementia?" How would the nurse respond about the purpose of the drug? A. "It will allow your mother to live independently for several more years." B. "It is used to halt the advancement of Alzheimer disease but will not cure it." C. "It will not improve her dementia but can help control emotional responses." D. "It is used to improve short-term memory but will not improve problem solving."

C. "It will not improve her dementia but can help control emotional responses."

A client with pneumonia and dementia is admitted with an indwelling urinary catheter in place. During interprofessional rounds the following day, which question would the nurse ask the primary health care provider? A. "Do you want daily weights on this client?" B. "Will the client be able to return home?" C. "May we discontinue the indwelling catheter?" D. "Should we get another chest x-ray today?"

C. "May we discontinue the indwelling catheter?"

The nurse teaches assistive personnel (AP) about how to care for a client with early-stage Alzheimer disease. Which statement would the nurse include? A. "If she is confused, play along and pretend that everything is okay." B. "Remove the clock from her room so that she doesn't get confused." C. "Reorient the client to the day, time, and environment with each contact." D. "Use validation therapy to recognize and acknowledge the client's concerns."

C. "Reorient the client to the day, time, and environment with each contact."

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? A. "The capsules can be opened and the powder sprinkled on applesauce if needed." B. "I will wipe my lips carefully after I drink the enzyme preparation." C. "The best time to take the enzymes is immediately after I have a meal or a snack." D. "I will not mix the enzyme powder with food or liquids that contain protein."

C. "The best time to take the enzymes is immediately after I have a meal or a snack."

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I don't understand the need for rehabilitation; the paralysis will not go away and it will not get better." How would the nurse respond? A. "If you don't want to participate in the rehabilitation program, I'll let your primary health care provider know." B. "Rehabilitation programs have helped many patients with your injury. You should give it a chance." C. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." D. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

C. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability."

A nurse is caring for an older client who is recovering from a leg amputation surgery. The client states, "I don't want to live with only one leg. I should have died during the surgery." What is the nurse's best response? A. "Your vital signs are good, and you are doing just fine right now." B. "Your children are waiting outside. Do you want them to grow up without a father?" C. "This is a big change for you. What support system do you have to help you cope?" D. "You will be able to do some of the same things as before you became disabled."

C. "This is a big change for you. What support system do you have to help you cope?"

A nurse teaches a client who is starting urinary bladder training. Which statement would the nurse include in this client's teaching? A. "Use the toilet when you first feel the urge, rather than at specific intervals." B. "Initially try to use the toilet at least every half hour for the first 24 hours." C. "Try to consciously hold your urine until the scheduled toileting time." D. "The toileting interval can be increased once you have been continent for a week."

C. "Try to consciously hold your urine until the scheduled toileting time."

A client with genital herpes has painful blisters on her vulva. After teaching the client self-care measures, which statement indicates the need for further education? A. "Pouring water over my genitals will decrease the pain of urinating." B. "I will wash my hands carefully after applying ointment." C. "When I don't have lesions, I am not contagious to my sexual partner." D. "I should increase my fluid intake when I have open lesions."

C. "When I don't have lesions, I am not contagious to my sexual partner."

A client has been treated for syphilis with IM penicillin. The next day the client calls the clinic to report fever, chills, achy muscles, and a worsening rash. What statement by the nurse is most appropriate? A. "You must be allergic to penicillin; over the counter antihistamines will help." B. "Please go to the nearest emergency department if you develop shortness of breath." C. "You can take acetaminophen or ibuprofen for the pain and achiness." "D. I think you should come in to the clinic either today or tomorrow and be checked."

C. "You can take acetaminophen or ibuprofen for the pain and achiness."

Which action by the nurse would most likely help to relieve symptoms associated with ascites? A. Monitoring serum albumin levels B. Lowering the head of the bed C. Administering oxygen therapy D. Administering intravenous fluids

C. Administering oxygen therapy

The nurse is teaching assistive personnel (AP) about hormones that are produced by the adrenal glands. Which hormone has the primary responsibility of maintaining fluid volume and electrolyte composition? A. Sodium B. Magnesium C. Aldosterone D. Renin

C. Aldosterone

A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute? A. Temperature of 100.1° F (37.8° C) B. Positive Murphy sign C. Clay-colored stools D. Upper abdominal pain after eating

C. Clay-colored stools

A nurse is assessing a client who presents with a scaly rash over the palms and soles of the feet and the feeling of muscle aches and malaise. Which action by the nurse is most appropriate? A. Reassure the client that these lesions are not infectious. B. Assess the client for hearing loss and generalized weakness. C. Don gloves and further assess the client's lesions. D. Take a history regarding any cardiovascular symptoms.

C. Don gloves and further assess the client's lesions.

The nurse is caring for a client who has cirrhosis of the liver. The client's latest laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor: A. deep vein thrombosis. B. Jaundice. C. Hematemesis. D. pressure injury.

C. Hematemesis.

A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion. Which complications would the nurse report to the primary health care provider? (Select all that apply.) A. Surgical discomfort B. Redness and itching at the incision site C. Incisional bulging D. Clear drainage on the dressing E. Sudden and severe headache

C. Incisional bulging D. Clear drainage on the dressing E. Sudden and severe headache

The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 What complication of acute pancreatitis would the nurse suspect that the client might have? A. Electrolyte imbalance B. Pleural effusion C. Internal bleeding D. Pancreatic pseudocyst

C. Internal bleeding

The nurse assesses a client who has possible gastritis. Which assessment finding(s) indicate(s) that the client has chronic gastritis? (Select all that apply.) A. Anorexia B. Dyspepsia C. Intolerance of fatty foods D. Pernicious anemia E. Nausea and vomiting

C. Intolerance of fatty foods D. Pernicious anemia

A nurse is caring for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication would the nurse most likely administer? A. Intravenous morphine B. Oral acetaminophen C. Intravenous calcitonin D. Oral ibuprofen

C. Intravenous calcitonin

A client is starting hormonal therapy with tamoxifen to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug? A. It blocks the release of luteinizing hormone. B. It interferes with cancer cell division. C. It selectively blocks estrogen in the breast. D. It inhibits DNA synthesis in rapidly dividing cells.

C. It selectively blocks estrogen in the breast.

The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? A. Blacks B. Asian/Pacific Islanders C. Latinos D. French

C. Latinos

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit. What action by the nurse is best? A. Ask if the weight loss was intended. B. Encourage a high-protein, high-fiber diet. C. Measure for new compression stockings. D. Review a 3-day food recall diary.

C. Measure for new compression stockings.

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? A. Drink only bottled water and avoid ice. B. Avoid sharing the bathroom with the client. C. Members of the household must not share toothbrushes. D. The client must not consume alcohol.

C. Members of the household must not share toothbrushes.

When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B? A. Clients who work with shellfish. B. Clients with elevations of aspartate aminotransferase and alanine aminotransferase. C. Men who engage in sex with men. E. Clients traveling to a third-world country.

C. Men who engage in sex with men.

A client had a surgical procedure with spinal anesthesia. The client's blood pressure was 122/78 mm Hg 30 minutes ago and is now 138/60 and the client reports nausea. What action by the nurse is best? A. Call the Rapid Response Team. B. Increase the IV fluid rate. C. Notify the primary health care provider. D. Nothing; this is expected.

C. Notify the primary health care provider

The nurse is caring for a client who had a closed reduction of the left arm and notes a large wet area of drainage on the cast. What action is the most important? A. Cut off the old cast. B. Document the assessment. C. Notify the primary health care provider. D.. Wrap the cast with gauze.

C. Notify the primary health care provider.

The nurse is teaching a group of college students about the importance of preventing meningitis. Which health promotion activity is the most appropriate for preventing this disease? A. Eating a well-balanced diet that is high in protein B. Having an annual physical examination C. Obtaining the recommended meningitis vaccination and boosters D. Identifying signs and symptoms for early treatment

C. Obtaining the recommended meningitis vaccination and boosters

A nurse cares for a client with a spinal cord injury. With which interprofessional health team member would the nurse collaborate to assist the client with activities of daily living? A. Social worker B. Physical therapist C. Occupational therapist D. Case manager

C. Occupational therapist

The nurse is assessing a client in sickle cell disease (SCD) crisis. What priority client problem will the nurse expect? A. Infection B. Pallor C. Pain D. Fatigue

C. Pain

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next? A. Initiate oxygen via a nasal cannula. B. Recheck the client's blood pressure. C. Palpate the bladder for distention. D. Administer a prescribed beta blocker.

C. Palpate the bladder for distention.

A woman is admitted to the hospital for antibiotic therapy for pelvic inflammatory disease. She is in pain, with a rating of 7 on a scale of 0-10. What comfort measure can the nurse delegate to assistive personnel (AP)? A. Administer acetaminophen with codeine. B. Apply an ice pack to the lower abdomen. C. Position the client in a semi-Fowler position. D. Teach the client to increase intake of fluids.

C. Position the client in a semi-Fowler position.

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. What actions would the nurse take? (Select all that apply.) A. Apply a barrier cream to protect the skin from excoriation. B. Perform range-of-motion (ROM) exercises for the hip joint. C. Reposition the client off of the reddened areas. D. Get the client out of bed and into a chair several times a day. E. Apply a pressure-reducing mattress.

C. Reposition the client off of the reddened areas. E. Apply a pressure-reducing mattress.

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What intervention would the nurse implement to address this client's concerns? A. Administer oxygen therapy at 2 L per nasal cannula. B. Provide the client with a sleeping pill to stimulate rest. C. Schedule periods of exercise and rest during the day. D. Ask assistive personnel (AP) to help bathe the client.

C. Schedule periods of exercise and rest during the day.

A client has just returned from a right radical mastectomy. Which action by the assistive personnel (AP) would require the nurse consider to intervene? A. Checking the amount of urine in the catheter collection bag B. Elevating the right arm on a pillow C. Taking the blood pressure on the right arm D. Encouraging the client to squeeze a rolled washcloth

C. Taking the blood pressure on the right arm

The nurse is planning a health teaching about omeprazole for a client who has acute gastritis. What would the nurse include in the health teaching? A. Crushing the drug and mixing in applesauce B. Avoiding alcohol while taking this drug C. Taking the drug 30 minutes before a meal D. Taking the drug when the client has gastric pain

C. Taking the drug 30 minutes before a meal

The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first? A. Start fluids via a large-bore catheter. B. Administer IV push diazepam. C. Turn the client's head to the side. D. Prepare to intubate the client.

C. Turn the client's head to the side.

A nurse is providing tracheostomy care. What action by the nurse requires intervention by the charge nurse? A. Holding the device securely when changing ties B. Suctioning the client first if secretions are present C. Tying a square knot at the back of the neck D. Using half-strength peroxide for cleansing

C. Tying a square knot at the back of the neck

The nurse assesses a client who has a history of migraines. Which symptom would the nurse identify as an early sign of a migraine with aura? A. Vertigo B. Lethargy C. Visual disturbances D. Numbness of the tongue

C. Visual disturbances

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L). B. An adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain. C. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. D. Middle-age client who has an elevated temperature after undergoing endoscopic retrograde

C. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min.

CHAPTER 20

CHAPTER 20

CHAPTER 25

CHAPTER 25

CHAPTER 28

CHAPTER 28

CHAPTER 31

CHAPTER 31

CHAPTER 32

CHAPTER 32

CHAPTER 33

CHAPTER 33

CHAPTER 37

CHAPTER 37

CHAPTER 39

CHAPTER 39

CHAPTER 40

CHAPTER 40

CHAPTER 47

CHAPTER 47

CHAPTER 49

CHAPTER 49

CHAPTER 50

CHAPTER 50

CHAPTER 53

CHAPTER 53

CHAPTER 54

CHAPTER 54

CHAPTER 56

CHAPTER 56

CHAPTER 61

CHAPTER 61

CHAPTER 62

CHAPTER 62

CHAPTER 65

CHAPTER 65

CHAPTER 69

CHAPTER 69

CHAPTER 9

CHAPTER 9

The nurse is teaching a client about the use of viscous lidocaine for oral pain. What health teaching would the nurse include? A. "Use the drug before every meal to prevent aspiration." B. "Increase your intake of citrus foods to help with healing." C. "Use the drug only at bedtime because you won't be eating." D. "Be sure to check food temperatures before eating."

D. "Be sure to check food temperatures before eating."

While evaluating a client for treatment of gonorrhea, which question is the most important for the nurse to ask? A. "Do you have a history of sexually transmitted infection?" B. "When was your last sexual encounter?" C. "When did your symptoms begin?" D. "Can you remember your partners and contact them to get treated?"

D. "Can you remember your partners and contact them to get treated?"

A nurse teaches assistive personnel (AP) about providing hygiene for a client in traction. Which statement would the nurse include as part of the teaching about this client's care? A. "Remove the traction when re-positioning the client." B. "Assess the client's skin when performing a bed bath." C. "Provide pin care by using alcohol wipes to clean the sites." D. "Ensure that the weights remain freely hanging at all times."

D. "Ensure that the weights remain freely hanging at all times."

After teaching a client who is diagnosed with new-onset epilepsy and prescribed phenytoin, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? A. "To prevent complications, I will drink at least 2 L of water daily." B. "This medication will stop me from getting an aura before a seizure." C. "I will not drive a motor vehicle while taking this medication." D. "Even when my seizures stop, I will continue to take this drug."

D. "Even when my seizures stop, I will continue to take this drug."

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands changes associated with this disease? A. "His masklike face makes it difficult to communicate, so I will use a white board." B. "He should not socialize outside of the house due to uncontrollable drooling." C. "This disease is associated with anxiety causing increased perspiration." D. "He may have trouble chewing, so I will offer bite-sized portions."

D. "He may have trouble chewing, so I will offer bite-sized portions."

A nurse is caring for a client who is recovering from an above-the-knee amputation and reports pain in the limb that was removed. How would the nurse respond? A. "The pain you are feeling does not actually exist." B. "This type of pain is common and will eventually go away." C. "Would you like to learn how to use imagery to minimize your pain?" D. "How would you describe the pain that you are feeling?"

D. "How would you describe the pain that you are feeling?"

The nurse is teaching a client who has been treated for acute gastritis. What statement by the client indicates a need for further teaching? A. "I need to cut down on drinking martinis every might." B. "I should decrease my intake of caffeinated drinks, especially coffee." C. "I will only take ibuprofen once in a while when I really need it." D. "I can continue smoking cigarettes which is better than chewing tobacco."

D. "I can continue smoking cigarettes which is better than chewing tobacco."

A client diagnosed with Parkinson disease will be starting ropinirole for symptom control. Which statement by the client indicates a need for further teaching? A. "This drug should help decrease my tremors and help me move better." B. "I need to change positions slowly to prevent dizziness or falls." C. "I should take the drug at the same time each day for the best effect." D. "I know the drug will probably make help me prevent constipation."

D. "I know the drug will probably make help me prevent constipation."

The nurse is teaching a client how to prevent recurrent chronic gastritis symptoms before discharge. Which statement by the client demonstrates a correct understanding of the nurse's instruction? A. "I will need to take vitamin B12 shots for the rest of my life." B. "I should eat small meals about six times a day." C. "It is okay to continue to drink coffee in the morning when I get to work." D. "I should avoid alcohol and tobacco of any type."

D. "I should avoid alcohol and tobacco of any type."

After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? A. "I will wear my medical alert bracelet at all times." B. "While taking my medications, I will not drink any alcoholic beverages." C. "I will tell my doctor about my prescription and over-the-counter medications." D. "If I am nauseated, I will not take my epilepsy medication."

D. "If I am nauseated, I will not take my epilepsy medication."

The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which statement to maintain client safety would the nurse include in the discharge teaching for the caregiver? A. "Provide periods of exercise and rest for the client." B. "Place a padded throw rug at the bedside." C. "Provide a highly stimulating environment." D. "Install safety locks on all outside doors."

D. "Install safety locks on all outside doors."

The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? A. "Follow up on all appointments to monitor your lab values." B. "Do not take amiodorone at any time while on this drug." C. "Monitor for jaundice, rash, and itchy skin while on this drug." D. "Report any changes in urinary elimination while on this drug."

D. "Report any changes in urinary elimination while on this drug."

The nurse is assessing a client who reports having a history of gastroesophageal reflux disease (GERD). Which assessment finding does the nurse report to the primary health care provider? A. "My family likes to eat small meals every 3 to 4 hours throughout the day." B. "When I buy meat, I ask for the leanest cut that is available." C. "I quit smoking 6 months ago." D. "Sometimes I wake up gasping for air in the middle of the night."

D. "Sometimes I wake up gasping for air in the middle of the night."

A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching? A. "Avoid drinking more than 3 quarts (3 L) of liquids each day." B. "Eat six small meals daily instead of three larger meals." C. "When you feel short of breath, take an additional diuretic." D. "Weigh yourself daily while wearing the same amount of clothing."

D. "Weigh yourself daily while wearing the same amount of clothing."

A nurse teaches a client with functional urinary incontinence. Which statement would the nurse include in this client's teaching? A. "You must clean around your catheter daily with soap and water." B. "You will need to be on your drug therapy for life." C. "Operations to repair your bladder are available, and you can consider these." D. "You might want to get pants with elastic waistbands."

D. "You might want to get pants with elastic waistbands."

A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, "The cast is loose enough to slide off." How would the nurse respond? A. "Keep your arm above the level of your heart." B. "As your muscles atrophy, the cast is expected to loosen." C. "I will wrap a bandage around the cast to prevent it from slipping." D. "You need a new cast now that the swelling is decreased."

D. "You need a new cast now that the swelling is decreased."

A 30-year-old male client is asking the nurse about the vaccine for human papilloma virus (HPV). Which statement by the nurse is accurate? A. "Gardasil protects against all HPV strains." B. "You are too old to receive the vaccine." C. "Only females can receive the vaccine." D. "You will only need 1 dose of the vaccine."

D. "You will only need 1 dose of the vaccine."

The nurse is performing a neurovascular assessment for an older client who has an extremity fracture. How many seconds would the nurse expect for a capillary refill if it is within normal range? A. 20 seconds B. 15 seconds C. 10 seconds D. 5 seconds

D. 5 seconds

A nurse assesses clients at a community center. Which client is at greatest risk for low back pain? A. A 24-year-old female who is 25 weeks pregnant. B. A 36-year-old male who uses ergonomic techniques. C. A 53-year-old female who uses a walker. D. A 65-year-old female with osteoarthritis.

D. A 65-year-old female with osteoarthritis.

A nurse is caring for several clients with fractures. Which client would the nurse identify as being at the highest risk for developing deep vein thrombosis? A. An 18-year-old male athlete with a fractured clavicle B. A 36-year-old female with type 2 diabetes and fractured ribs C. A 55-year-old female prescribed ibuprofen for osteoarthritis D. A 74-year-old male who smokes and has a fractured pelvis

D. A 74-year-old male who smokes and has a fractured pelvis

The nurse is admitting a client who has acute glomerulonephritis caused by beta streptococcus. What drug therapy would the nurse expect to be prescribed for this client? A. Antihypertensives B. Antilipidemics C. Antidepressants D. Antibiotics

D. Antibiotics

A client with pelvic inflammatory disease is seen by the nurse 72 hours after starting oral antibiotics. Which finding leads the nurse to take immediate action? A. Feelings of anger that her partner infected her B. Loose stools over the last 2 days C. Anorexia and nausea D. Chills and a temperature of 101° F (38.3° C)

D. Chills and a temperature of 101° F (38.3° C)

The nurse is caring for a postoperative client who has a regional nerve blockade for a surgical tibial fracture repair this morning. What assessment finding would the nurse expect? A. Client reports nausea and vomiting. B. Client reports tingling in the surgical leg. C. Client responds well to imagery. D. Client reports little to no pain.

D. Client reports little to no pain.

The nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first? A. Assess level of consciousness. B. Obtain vital signs. C. Administer oxygen therapy. D. Evaluate respiratory status.

D. Evaluate respiratory status.

The postoperative nurse is caring for a client who reports feeling "something popped" after vomiting. What action by the nurse is best? A. Administer an antiemetic medication. B. Call the primary health care provider. C. Instruct client to avoid coughing. D. Gather sterile nonadherent dressings.

D. Gather sterile nonadherent dressings.

A nurse assesses a client with a pelvic fracture. Which assessment finding would the nurse identify as a complication of this injury? A. Hypertension B. Diarrhea C. Infection D. Hematuria

D. Hematuria

The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? A. Metabolic syndrome B. Liver cancer C. Nonalcoholic fatty liver disease D. Hepatitis C

D. Hepatitis C

The nurse teaches a client who has stress incontinence methods to regain more urinary continence. Which health teaching is the most important for the nurse to include for this client? A. What type of incontinence pads to use? B. What types of liquids to drink and when? C. Need to perform intermittent catheterizations. D. How to do Kegel exercises to strengthen muscles?

D. How to do Kegel exercises to strengthen muscles?

The nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client's plan of care? A. Restrain the client to prevent falling. B. Ensure that the client uses incentive spirometry. C. Teach the client pursed-lip breathing techniques. D. Keep the head of the bed at 30 degrees or greater.

D. Keep the head of the bed at 30 degrees or greater.

An older client who fell at home is admitted to the emergency department and reports pain in her left groin and behind her left knee. What action would the nurse anticipate? A. Administer IV push morphine. B. Prepare for application of a leg cast. C. Begin oxygen at 6 L/min via mask. D. Obtain a left hip x-ray.

D. Obtain a left hip x-ray.

Which of these client assessment findings is typically associated with oral cancer? A. Dry sticky oral membranes B. Increased appetite C. Itchy rash in oral cavity D. Painless red or raised lesion

D. Painless red or raised lesion

A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse requires the nurse's mentor to intervene? A. Assesses the client for back pain. B. Auscultates over abdominal bruit. C. Measures the abdominal girth. D. Palpates the abdomen in four quadrants.

D. Palpates the abdomen in four quadrants.

The nurse is caring for a client experiencing sickle cell disease crisis. Which priority action would help prevent infection? A. Administering prophylactic antibiotics B. Monitoring the client's temperature C. Checking the client's white blood cell count D. Performing frequent handwashing

D. Performing frequent handwashing

A nurse is preparing to administer a blood transfusion. Which action is most important? A. Document the transfusion. B. Place the client on NPO status. C. Place the client in isolation. D. Put on a pair of gloves.

D. Put on a pair of gloves.

A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action by the nurse is best? A. Ensure the client is placed in protective isolation. B. Have pregnant visitors stay 6 feet from the client C. No special action is necessary to care for this client. D. Read the policy on handling radioactive excreta.

D. Read the policy on handling radioactive excreta.

After teaching a client with a fractured humerus, the nurse assesses the client's understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture? A. Baked fish with orange juice and a vitamin D supplement B. Bacon, lettuce, and tomato sandwich with a vitamin B supplement C. Vegetable lasagna with a green salad and a vitamin A supplement D. Roast beef with low-fat milk and a vitamin C supplement

D. Roast beef with low-fat milk and a vitamin C supplement

A nurse plans care for a client who has an external fixator on the lower leg. Which intervention would the nurse include in the plan of care to decrease the client's risk for infection? A. Washing the frame of the fixator once a day B. Releasing fixator tension for 30 minutes twice a day C. Avoiding moving the extremity by holding the fixator D. Scheduling for pin care to be provided every shift

D. Scheduling for pin care to be provided every shift

The nurse is collaborating with the occupational therapist to assist a client with a complete cervical spinal cord injury to transfer from the bed to the wheelchair. What ambulatory aid would be most appropriate for the client to meet this outcome? A. Rolling walker B. Quad cane C. Adjustable crutches D. Sliding board

D. Sliding board

The nurse collaborates with the registered dietitian nutritionist in providing teaching for a client who has ascites from cirrhosis. What daily dietary restriction would the nurse include in the health teaching? A. Calcium B. Potassium C. Magnesium D. Sodium

D. Sodium

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? A. Call the operating room to inform them of a pending emergency case. B. No action is needed at this time; this is a normal finding in some clients. C. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. D. Stay with the client and have someone else call the primary health care provider immediately.

D. Stay with the client and have someone else call the primary health care provider immediately.

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment would the nurse wear? (Select all that apply.) A. Particulate respirator B. Isolation gown C. Shoe covers D. Surgical mask E. Gloves

D. Surgical mask E. Gloves

A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority? A. Helping clients adjust to their appearance B. Reassuring clients that this change is temporary C. Referring clients to a reputable wig shop D. Teaching measures to prevent scalp injury

D. Teaching measures to prevent scalp injury

The nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this type of seizure? A. Atonic B. Myoclonic C. Absence D. Tonic-clonic

D. Tonic-clonic

A client continues to have persistent low back pain even after using a number of nonpharmacologic pain management strategies. Which prescribed drug would the nurse anticipate that the client might need to manage the pain? A. Oxycontin B. Gabapentin C. Lorazepam D. Tramadol

D. Tramadol

A nurse plans care for a client with overflow incontinence. Which intervention does the nurse include in this client's plan of care to assist with elimination? A. Stroke the medial aspect of the thigh. B. Use intermittent catheterization. C. Provide digital anal stimulation. D. Use the Valsalva maneuver.

D. Use the Valsalva maneuver.

A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate? A. Crush the medications if the client cannot swallow them. B. Give one medication at a time with a full glass of water. C. No special precautions are needed for these medications. D. Wear personal protective equipment when handling the medications.

D. Wear personal protective equipment when handling the medications.

A brief jerking or stiffening of extremities that may occur singly or in groups.

Myoclonic seizure

Pathophysiology of nephrotic syndrome

Nephrotic syndrome happens when the glomeruli are damaged and can't properly filter your blood. Damage to these blood vessels allows protein to leak into your urine. Albumin is one of the proteins lost in your urine. Albumin helps pull extra fluid from your body into your kidneys.

Risks that pyelonephritis on the pregnant woman

pregnant women require immediate and effective treatment to prevent pyelonephritis can result in PRETERM LABOR

Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities,

tonic-clonic seizure.