trying

अब Quizwiz के साथ अपने होमवर्क और परीक्षाओं को एस करें!

The nurse is assessing a client whose respiratory disease is characterized by chronic hyperinflation of the lungs . Which physical characteristic would the nurse most likely observe in this client ? A. Signs of oxygen toxicity B. A moon face C. A barrel chest D. Long , thin fingers

. A barrel chest

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

200 cells / mm³ of blood

The nurse is assessing a diverse group of clients . What client is at a greater risk for the development of hypothyroidism ?A. A 75 - year - old female client with osteoporosis B. A 50 - year - old male client who is obese C. A 45 - year - old female client who uses oral contraceptives D. A 25 - year - old male client who uses recreational drugs

A 75 - year - old female client with osteoporosis

A female client is being admitted postoperatively to the surgical floor after a radical vulvectomy . What minimum equipment and interventions should the nurse anticipate and prepare for ? Select all that apply . A. An intravenous infusion pump for antibiotics B. A Bair hugger warming blanket to prevent hypothermia C. A private or single room for neutropenic isolation D. Portable suction for postoperative nausea and vomiting E. Sequential compression devices to reduce the risk of venous thromboembolism

A. An intravenous infusion pump for antibiotics E. Sequential compression devices to reduce the risk of venous thromboembolism

The cardiac care nurse is reviewing the conduction system of the heart . The nurse is aware that electrical conduction of the heart usually originates in the sinoatrial ( SA ) node and then proceeds in which sequence ? A. Bundle of His to atrioventricular ( AV ) node to Purkinje fibers B. AV node to Purkinje fibers to bundle of His C. Bundle of His to Purkinje fibers to AV node D. AV node to bundle of His to Purkinje fibers

AV node to bundle of His to Purkinje fibers

Which issue has most often presented challenging ethical issues , especially in the context of palliative care ? A. Increased cultural diversity B. Staffing shortages in health care and questions concerning quality of care C. Increased costs of health care coupled with inequalities in access D. Ability of technology to prolong life beyond meaningful quality of life

Ability of technology to prolong life beyond meaningful quality of life

Herpes zoister give what mediation?

Acyclovir

A nurse reviewing the trend of a client's scores on the Glasgow Coma Scale ( GCS ) . This provides what potential information to the nurse about the client's status ? A. The client's level of knowledge about preceding events B. An assessment of the client's current level of consciousness C. An assessment of the client's lowest verbal and physical response to stimuli D. An in - depth and real - time neurological assessment of the client's condition

An assessment of the client's current level of consciousness

An office worker eats a cookie that contains peanut butter The worker begins wheezing , with an inspiratory stridor and air hunger , and the occupational health nurse is called to the office . The nurse should recognize that the worker is likely suffering from which type of hypersensitivity ? A. Anaphylactic ( type 1 ) B. Cytotoxic ( type II ) C. Immune complex ( type III ) D. Delayed type ( type IV )

Anaphylactic ( type 1 )

A gardener sustained a deep laceration while working and requires sutures . The date of the client's last tetanus shot was over 10 years ago . Based on this information , the client will receive tetanus immunization , which will allow for the release of which type of substance ? A. Antibodies B. Antigens C. Cytokines D. Phagocytes

Antibodies

What medications cause blood loss

Anticoagulants

A perioperative nurse is caring for a postoperative client . The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing . The nurse should address the client's increased risk for what complication ? A. Acute respiratory distress syndrome ( ARDS ) B. Atelectasis C. Aspiration D. Pulmonary embolism

Atelectasis

A surgical nurse is preparing to enter the restricted zone of the operating room . Which surgical attire should this nurse wear ? Select all that apply . A. Street clothes . B. Cap C. Mask D. Shoe covers E. Scrub clothes

B. Cap C. Mask D. Shoe covers E. Scrub clothes

A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron - deficiency anemia in recent weeks . When providing the client with nutritional guidelines and meal suggestions , what foods would be most likely to increase the woman's iron stores ? A. Salmon accompanied by whole milk B. Mixed vegetables and brown rice C. Beef liver accompanied by orange juice D. Yogurt , almonds , and whole grain oats

Beef liver accompanied by orange juice

A clinic nurse is caring for a client with a history of osteoporosis . What diagnostic test will best allow the care team to assess the client's risk of fracture ? A. Arthrography B. Bone scan C. Bone densitometry D. Arthroscopy

Bone densitometry

A client is scheduled for a skin test . The client informs the nurse that the client used corticosteroid earlier today to alleviate allergy symptoms . Which nursing intervention should the nurse implement ? A. Note the corticosteroid use in the electronic health record and continue with the test . B. Modify the skin test to check for grass , mold , or dust allergies only . C. Administer sodium valproate to reverse the effects of corticosteroid usage .D. Cancel and reschedule the skin test when the client stops taking the corticosteroid .

Cancel and reschedule the skin test when the client stops taking the corticosteroid .

A school nurse is teaching a group of high school students about risk factors for diabetes . What action has the greatest potential to reduce an individual's risk for developing diabetes ? A. Have blood glucose levels checked annually . B. Stop using tobacco in any form . C. Undergo eye examinations regularly . D. Lose weight , if obese .

Lose weight , if obese .

A nurse is teaching an educational class to a group of older adults at a community center . In an effort to prevent osteoporosis , the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients ? Select all that apply . A. Vitamin B12 B. Potassium C. Calcitonin D. Calcium E. Vitamin D

D. Calcium E. Vitamin D

A client with diabetes is asking the nurse what causes diabetic ketoacidosis ( DKA ) . Which of the following is a correct statement by the nurse ? A. " DKA can be caused by taking too much insulin . " B. " DKA can be caused by taking too little insulin . " C. " DKA can happen without a cause . " D. " DKA will not happen with type 1 diabetes . "

DKA can be caused by taking too little insulin . "

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

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

A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color . How should the nurse best respond to this assessment finding ? A. Irrigate the ostomy to clear a possible obstruction . B. Contact the primary care provider to report this finding . C. Document that the stoma appears healthy and well perfused . D. Document a nursing diagnosis of Impaired Skin Integrity .

Document that the stoma appears healthy and well perfused .

The nurse in the ED is caring for a child brought in by the parents who state that the child will not stop crying and pulling at the child's ear . Based on information collected by the nurse , which of the following statements applies to a diagnosis of external otitis ? A. External otitis is characterized by aural tenderness . B. External otitis is usually accompanied by a high fever . C. External otitis is usually related to an upper respiratory infection . D. External otitis can be prevented by using cotton - tipped applicators to clean the ear .

External otitis is characterized by aural tenderness

During a routine mammogram , client asks the nurse whether breast cancer causes the most deaths . Which type of cancer is the leading cause of death in the United States ? A. Colorectal B. Prostate C. Lung D. Breastfeeding

Lung

A client presents to the clinic reporting stanke symptoms that suggest diabetes . What criteria would support checking blood levels for the diagnosis of diabetes ? A. Fasting plasma glucose greater than or equal to 126 mg / dL ( 7.0 mmol / L ) B. Random plasma glucose greater than 150 mg / dL ( 8.3 mmol / L ) C. Fasting plasma glucose greater than 116 mg / dL ( 6.4 mmol / L ) on two separate occasions D. Random plasma glucose greater than 126 mg / dL ( 7.0 mmol / L )

Fasting plasma glucose greater than or equal to 126 mg / dL ( 7.0 mmol / L )

The nurse's aide notifies the nurse that a client has decreased om tachypneic oxygen saturation levels . The nurse assesses the client and finds that the client is , has crackles on auscultation , and has frothy and pink sputum . The nurse should suspect which complication ? A. Pulmonary embolism B. Atelectasis C. Laryngospasm D. Flash pulmonary edema

Flash pulmonary edema

An older adult client with type 2 diabetes is brought to the emergency department by the client's daughter . The client is found to have a blood glucose level of 600 mg / dL ( 33.3 mmol / L ) . The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours . The diagnosis of hyperglycemic hyperosmolar syndrome ( HHS ) is made . What nursing action would be a priority ? A. Administration of antihypertensive medications B. Administering sodium bicarbonate intravenously C. Reversing acidosis by administering insulin D. Fluid and electrolyte replacement

Fluid and electrolyte replacement

A client is brought to the emergency department from the site of a chemical fire , where the client suffered a burn that involves the epidermis , dermis , and the muscle and bone of the right arm . On inspection , the skin appears charred . Based on these assessment findings , what is the depth of the burn on the client's arm ? A. Superficial partial thickness B. Deep partial thickness C. Full partial thickness D. Full thickness

Full thickness

A client exhibiting an altered level of consciousness ( LOC ) due to blunt force trauma to the head is admitted to the emergency department ( ED ) . The nurse should first gauge the client's LOC on the results of what diagnostic tool ? A. Monro - Kellie hypothesisB. Glasgow Coma scale C. Cranial nerve function D. Mental status examination

Glasgow Coma scale

A client is brought into the emergency department ( ED ) by family members , who tell the nurse the client grabbed their chest and reported substernal chest pain . The care team recognizes the need to monitor the client's cardiac function closely while interventions are performed . Which form of monitoring should the nurse anticipate ? A. Left - sided heart catheterization B. Cardiac telemetry C. Transesophageal echocardiography D. Hardwire continuous electrocardiogram ( ECG ) monitoring

Hardwire continuous electrocardiogram ( ECG ) monitoring

What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I ? A. Have the client identify familiar odors with the eyes closed . B. Assess papillary reflex . C. Utilize the Snellen chart . D. Test for air and bone conduction ( Rinne test ) .

Have the client identify familiar odors with the eyes closed .

A client has received a diagnosis of irritant contact dermatitis What action should the nurse prioritize in the client's subsequent care ? A. Teaching the client to safely and effectively administer immunosuppressants B. Helping the client identify and avoid the offending agent C. Teaching the client how to maintain meticulous skin hygiene D. Helping the client perform wound care in the home environment

Helping the client identify and avoid the offending agent

A client asks the nursing assistant for a bedpan . When the client is finished , the nursing assistant notifies the nurse that the client has bright red streaking of blood in the stool . The nurse's assessment should focus on what potential cause ? A. Diet high in red meat B. Upper GI bleed ba C. Hemorrhoids

Hemorrhoids

A clinic client has described recent dark - colored stools , and the nurse recognizes the need for fecal occult blood testing ( FOBT ) . What aspect of the client's current health status would contraindicate FOBT ? A. Gastroesophageal reflux disease ( GERD ) B. Peptic ulcers C. Hemorrhoids D. Recurrent nausea and vomiting

Hemorrhoids webanks.com

1-2 bowel sounds heard in 2 minutes?

Hypoactive bowel sounds

The nurse is preparing an elderly client for a scheduled removal of orthopedic hardware , a procedure to be performed under general anesthetic . For which adverse effect should the nurse most closely monitor the client ? A. Hypothermia B. Pulmonary edema C. Cerebral ischemia D. Arthritis

Hypothermia

00 A client with long - standing obesity has been prescribed phentermine / topiramate - ER . What statement by the client suggests that further health education is necessary ? A. " I'm so relieved to start this medication . I really don't like having to exercise or change what I eat . " B. " It's hard to believe that there are actually medications that can treat obesity . " C. " I'm a bit nervous to start this medication because I know I'll need blood tests sometimes . D. " I'm going to have to do some arranging of my finances to make sure I can afford this medication

I'm so relieved to start this medication . I really don't like having to exercise or change what I eat . "

An older adult client , who is bedridden , is admitted to the unit because of a pressure injury that can no longer be treated in a community setting . During assessment , the nurse finds that the ulcer extends into the muscle and bone . At what stage should the nurse document this injury ? A. I B. IIC. III D. IV

IV

A client with HIV will be receiving care in the home setting . What aspect of self - care should the nurse emphasize during discharge education ? A. Appropriate use of prophylactic antibiotics B. Importance of personal hygiene C. Signs and symptoms of wasting syndrome

Importance of personal hygiene

Urinay catheter is at risk for?

Infection

Gi assessment order

Inspect, auscultation, percus,palpate

A client comes to the clinic reporting fatigue and the health interview is suggestive of pica . Laboratory findings reveal a low serum iron level and a low ferritin level . With what would the nurse suspect that the client will be diagnosed ? A. Iron deficiency anemia B. Pernicious anemia C. Sickle cell disease

Iron deficiency anemia

Several residents of a long - term care facility have developed signs and symptoms of viral conjunctivitis . What is the most appropriate action of the nurse who oversees care in the facility ? A. Arrange for the administration of prophylactic antibiotics to unaffected residents . B. Instill normal saline into the eyes of affected residents two to three times daily . C. Swab the conjunctiva of unaffected residents for culture and sensitivity testing . D. Isolate affected residents from residents who have not developed conjunctivitis .

Isolate affected residents from residents who have not developed conjunctivitis .

A client has developed severe contact dermatitis with burning , itching , cracking , and peeling of the skin on the client's hands . What should the nurse teach the client to do ? A. Wear powdered latex gloves when in public . B. Wash her hands with antibacterial soap every few hours . C. Maintain room temperature at 75 to 80 ° F ( 24 ° to 27 ° C ) whenever possible . D. Keep the hands well moisturized at all times .

Keep the hands well moisturized at all times .

The intraoperative nurse is transferring a client from the OR to the PACU after replacement of the right knee . The client is an older adult . The nurse should prioritize which of the following actions ? A. Keeping the client sterile B. Keeping the client restrained D. Keeping the client hydrated C. Keeping the client warm .

Keeping the client warm

During a shift assessment , the nurse is identifying the client's point of maximum impulse ( PMI ) . Where should the nurse best palpate the PMI ? A. Left midclavicular line of the chest at the level of the nipple B. Left midclavicular line of the chest at the fifth intercostal space C. Midline between the xiphoid process and the left nipple D. Two to three centimeters to the left of the sternum

Left midclavicular line of the chest at the fifth intercostal space

A nurse who provides care in a long - term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults . What action has the greatest potential to prevent UTIS in this population ? A. Administer prophylactic antibiotics as prescribed . B. Limit the use of indwelling urinary catheters . C. Encourage frequent mobility and repositioning . D. Toilet residents who are immobile on a scheduled basis .

Limit the use of indwelling urinary catheters .

A nurse is talking with a client who is scheduled to have a hemicolectomy with the creation of a colostomy . The client admits to being anxious , and has many questions concerning the surgery , the care of a stoma , and necessary lifestyle changes . What nursing action is most appropriate ? A. Reassure the client that the procedure is relatively low risk and that clients are usually successful in adjusting to an ostomy . B. Provide the client with educational materials that match the client's learning style . C. Encourage the client to write down these concerns and questions to bring forward to the surgeon . D. Maintain an open dialogue with the client and facilitate a referral to the wound - ostomy - continence ( WOC ) nurse .

Maintain an open dialogue with the client and facilitate a referral to the wound - ostomy - continence ( WOC ) nurse .

While performing an initial assessment of a client admitted with of appendicitis , the nurse observes an elevated blue - black lesion on the client's ear . The nurse knows that this lesion is consistent with what type of skin cancer ? A. Basal cell carcinoma B. Squamous cell carcinoma C. Dermatofibroma D. Malignant melanoma

Malignant melanoma

Same day surgery ristricions

Need a ride home

When caring for a client with an altered level of consciousness , the nurse is preparing to test cranial nerve VII . What assessment technique would most likely elicit a response from cranial nerve VII ?A. Palpate trapezius muscle while client shrugs shoulders against resistance . B. Administer the whisper or watch tick test . C. Observe for facial movement symmetry , such as a smile . D. Note any hoarseness in the client's voice .

Observe for facial movement symmetry , such as a smile .

The nurse is performing a health assessment of a client who o has been taking antiobesity medications for several weeks . During the nurse's gastrointestinal assessment , the client reports bowel movements described as " greasy " and " oily . " What medication is the client most likely taking ? A. Lorcaserin B. Orlistat C. Liraglutide D. Phentermine

Orlistat

The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa . What assessment finding is characteristic of this diagnosis ? A. Tophi on the pinna and ear lobe B. Dark yellow cerumen in the C. Pain on manipulation of the auricle external auditory canal . D. Air bubbles visible in the middle ear

Pain on manipulation of the auricle

A client asks the nurse why an infection in the upper respiratory system is affecting the clarity of the client's speech . The nurse should describe the role of what structure ? A. Trachea B. Pharynx C. Paranasal sinuses . D. Larynx

Paranasal sinuses

The operating room nurse acts in the circulating role during a client's scheduled cesarean section . For which task is this nurse responsible ? A. Performing documentation B. Estimating the client's blood loss . C. Setting up the sterile tables D. Gives the surgeon instruments during surgery

Performing documentation

The nurse is providing education to a client diagnosed with acute rhinosinusitis . For which possible complication should the nurse teach the client to seek follow - up care ? A. Periorbital edema B. Headache unrelieved by over - the - counter medications C. Clear drainage from nose D. Blood - tinged mucus when blowing the nose

Periorbital edema

Optional surgery

Plastic surgery

The nurse is caring for a client who has returned to the unit following a bronchoscopy . The client is asking for something to drink . Which criterion will determine when the nurse should allow the client to drink fluids ? A. Presence of a cough and gag reflex B. Absence of nausea C. Ability to demonstrate deep inspiration D. Oxygen saturation of greater than or equal to92 %

Presence of a cough and gag reflex

. A nurse is caring for a newly admitted client with a suspected GI bleed . The nurse assesses the client's stool after a bowel movement and notes it to be a tarry - black color . This finding is suggestive of bleeding from what location ? A. Sigmoid colon B. Upper GI tract C. Large intestine D. Anus or rectum

Upper GI tract

Which nursing action best demonstrates primary cancer prevention ? A. Encouraging yearly Pap tests B. Teaching testicular self - examination C. Promoting and providing vaccines D. Facilitating screening mammograms

Promoting and providing vaccines

The home health nurse is caring for a homebound client who is terminally ill and is delivering a client - controlled analgesia ( PCA ) pump at today's visit . The family members will be taking care of the client . What would the nurse's priority interventions be for this visit ?A. Teach the family the theory of pain management and the use of alternative therapies . B. Provide psychosocial family support during this emotional experience C. Provide client and family teaching regarding the operation of the pump , monitoring the IV site , and knowing the side effects of the medication . D. Provide family teaching regarding use of morphine , recognizing morphine overdose and offering spiritual guidance

Provide client and family teaching regarding the operation of the pump , monitoring the IV site , and knowing the side effects of the medication

A nurse is writing a care plan for a client admitted to the emergency department ( ED ) with an open fracture . The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius ? A. Risk for infection B. Risk for ineffective role performance C. Risk for perioperative positioning injury D. Risk for powerlessness

Risk for infection

A nurse is writing a care plan for a client admitted to the emergency department with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius?

Risk for infection

A public health nurse has formed an interdisciplinary team that is developing an educational program entitled Cancer : The Risks and What You Can Do About Them . Participants will receive information , but the major focus will be screening for relevant cancers . This program is an example of what type of health promotion activity ? A. Disease prophylaxis B. Risk reduction C. Secondary prevention D. Tertiary prevention

Secondary prevention

The public health nurse is presenting a health promotion class to a group at a local community center . Which intervention most directly addresses the leading cause of cancer deaths in North America ? A. Monthly self - breast exams B. Smoking cessation . C. Annual colonoscopies D. Monthly testicular exams

Smoking cessation

A client has returned to the medical unit after a barium enema . When assessing the client's subsequent bowel patterns and stools , what finding would warrant reporting to the health care provider ? A. Large , wide stools B. Milky white stools . C. Three stools during an 8 - hour period of time D. Streaks of blood present in the stool

Streaks of blood present in the stool

A 42 - year - old woman comes to the clinic reporting occasional urinary incontinence when sneezing . The clinic nurse should recognize what type of incontinence ? A. Stress incontinence B. Reflex incontinence C. Overflow incontinence D. Functional incontinence

Stress incontinence

The nurse is admitting a 52 - year - old father of four into hospice care . The client has a diagnosis of Parkinson disease , which is progressing rapidly . The client has made clear his preference to receive care at home . What intervention should the nurse prioritize in the plan of care ? A. Aggressively continuing to fight the disease process B. Moving the client to a long - term care facility when it becomes necessary C. Including the children in planning their father's care D. Supporting the client's and family's values and choices

Supporting the client's and family's values and choices

The nurse is admitting a 52-year-old father of four into hospice care. The client has a diagnosis of Parkinson's disease which is progressing rapidly. The client has made clear his preference to receive care at home. What intervention should the nurse prioritize in the plan of care?

Supporting the clients and families, values and choices

The ED nurse is caring for an 11 - year - old brought in by ambulance after having been hit by a car . The child's parents are thought to be en route to the hospital but have not yet arrived . No other family members are present , and attempts to contact the parents have been unsuccessful . The child needs emergency surgery to survive . How should the need for informed consent be addressed ?A. A social worker should temporarily sign the informed consent . B. Consent should be obtained from the hospital's ethics committee . C. Surgery should be done without informed consent . D. Surgery should be delayed until the parents arrive .

Surgery should be done without informed consent .

A client admitted to the medical unit with impaired renal function reports severe , stabbing pain in the flank and lower abdomen . The client is being assessed for renal calculi . The nurse recognizes that the stone is most likely in what anatomic location ? A. Meatus B. Bladder C. Ureter D. Urethra

Ureter

A client is exploring treatment options after being diagnosed with age - related cataracts that affect her vision . What treatment is most likely to be used in this client's care ? A. Antioxidant supplements , vitamin C and E , beta - carotene , and selenium B. Eyeglasses or magnifying lenses C. Corticosteroid eye drops D. Surgical intervention

Surgical intervention

A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller . The instructor categorizes this as what action ? A. Systole B. Diastole C. Repolarization D. Ejection fraction

Systole

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

Tachypnea and restlessness

al The clinic nurse is preparing a plan of care for a client with a history of stress incontinence . What role will the nurse have in implementing a behavioral therapy approach ? A. Provide medication teaching related to pseudoephedrine sulfate . B. Teach the client to perform pelvic floor muscle exercises . C. Prepare the client for an anterior vaginal repair procedure . D. Provide information on periurethral bulking .

Teach the client to perform pelvic floor muscle exercises

A client with cancer has just been told that the disease is now terminal. The client cheerfully states I can't believe I'm going to die. Why me? What is the nurses? Best response to listen more information from the client?

Tell me more about how you feel about this news

A client with cancer has just been told that the disease is now terminal . The client tearfully states , " I can't believe I am going to die . Why me ? " What is the nurse's best response to elicit more information from the client ? A. " I know how you are feeling . " B. " You have lived a long life ; that should bring you peace . " C. " Tell me more about how you feel about this news . " D. " Life can be so unfair . "

Tell me more about how you feel about this news . "

Fiberglas cast

Temperature, movement, neuro

The admitting nurse in a short - stay surgical unit is responsible for forman numerous aspects of care . What must the nurse verify before the client is taken to the preoperative holding area ? A. That preoperative teaching was performed B. That the family is aware of the length of the surgery C. That follow - up home care is not necessary D. That the family understands the client will be discharged immediately after surgery .

That preoperative teaching was performed

The nurse is caring for an unconscious trauma client who needs emergency surgery . The client has an adult child , is legally divorced , and is planning to marry a partner in a few weeks . The client's parents are at the hospital with the other family members . The health care provider has explained the need for surgery , the procedure to be done , and the risks to the child , the parents , and the partner . Who should be asked to sign the surgery consent form ? A. The partner B. The child C. The health care provider , acting as a surrogate D. The client's father

The child

The nurse is caring for an unconscious trauma client who needs emergency surgery . The client has an adult child , is legally divorced , and is planning to marry a partner in a few weeks . The client's parents are at the hospital with the other family members . The health care provider has explained the need for surgery , the procedure to be done , and the risks to the child , the parents , and the partner . Who should be asked to sign the surgery consent form ? A. The partner B. The child C. The health care provider , acting as a surrogate D. The client's father .

The child

The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer disease . When obtaining informed consent , who is legally responsible for signing ? A. The client's next of kin B. The client's spouse C. The client D. The surgeon

The client

The nurse is taking the client into the operating room OR ) when the client informs the nurse that the client's grandparent spiked a very high temperature in the OR and nearly died 15 years ago . What relevance does this information have regarding the client ? A. The client may be experiencing presurgical anxiety . B. The client may be at risk for malignant hyperthermia . C. The grandparent's surgery has minimal relevance to the client's surgery . D. The client may be at risk for a sudden onset of postsurgical infection .

The client may be at risk for malignant hyperthermia .

A client has been diagnosed with serous otitis media for the third time in the past year . How should the nurse best interpret this client's health status ? A. For some clients , these recurrent infections constitute an age - related physiologic change . B. The client would benefit from a temporary mobility restriction to facilitate healing . C. The client needs to be assessed for nasopharyngeal cancer .

The client needs to be assessed for nasopharyngeal cancer .

The nurse is assessing a client with obesity who has been taking naltrexone / bupropion for the past several weeks . What assessment finding most clearly suggests that the medication is having a desired effect ? A. The client reports a diminished appetite and fewer cravings . B. The client is having one to two bowel movements daily , with fat present in stool . C. The client is losing at least 6 pounds ( 2.7 kg ) per week , on average . D. The client able to adhere to a low - carbohydrate , high - protein diet .

The client reports a diminished appetite and fewer cravings .

The nurse is performing a respiratory assessment of an adult client and is distinguishing between vesicular , bronchovesicular , and bronchial ( tubular ) breath sounds . How should the nurse distinguish between these normal breath sounds ? A. Their location over a specific area of the lung B. The volume of the sounds

Their location over a specific area of the lung

A client with chronic lung disease is undergoing lung function testing . What test result denotes the volume of air inspired and expired with a normal breath ?A. Total lung capacity B. Forced vital capacity C. Tidal volume D. Residual volume

Tidal volume

A medical nurse is S providing palliative care to a client with a diagnosis of end - stage chronic obstructive pulmonary disease ( COPD ) . What is the primary goal of this nurse's care ? A. To improve the client's and family's quality of life B. To support aggressive and innovative treatments for cure C. To provide physical support for the client D. To help the client develop a separate plan with each discipline of the health care team

To improve the client's and family's quality of life

A teenage client is brought to the emergency department with symptoms of hyperglycemia . Based on the fact that the pancreatic beta cells are being destroyed , the client would be diagnosed with what type of diabetes ? A. Type 1 diabetes B. Type 2 diabetes C. Non - insulin - dependent diabetes D. Prediabetes

Type 1 diabetes

A client has sought care , stating that the client developed hives overnight . The nurse's inspection confirms the presence of urticaria . What type of allergic hypersensitivity reaction has the client developed ? A. Type I B. Type II C. Type III D. Type IV

Type I

A client is admitted to the ED reporting severe abdominal pain and vomiting " coffee - ground " like emesis . The client is diagnosed with a perforated gastric ulcer and is informed that they need surgery . When can the client most likely anticipate that the surgery will be scheduled ? A. Within 24 hours C. Without delay B. Within the next week D. As soon as all the day's elective surgeries have been completed

Without delay

A client is admitted to the ED reporting, severe abdominal pain and vomiting, coffee ground like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that they need surgery. When can the client most likely anticipate that the surgery will be scheduled?

Without delay

The nurse is admitting a client to the medical - surgical unit from the PACU . In order to help the client clear secretions and help prevent pneumonia the nurse should encourage the client to : A. eat a balanced diet that is high in protein . B. limit activity for the first 72 hours . C. take medications as prescribed . D. use the incentive spirometer every 2 hours .

use the incentive spirometer every 2 hours

A client with obesity is early in the process of preparing for a Roux en - Y gastric bypass ( RYGB ) . The client states , " After the surgery , the amount of food that I consume will be limited and I'll absorb fewer calories from what I do eat . " When responding to the client , the nurse should : A. explain that the surgery will not affect the absorption of nutrients . B. validate what the client understands about the surgical procedure . C. teach the client that RYGB does not restrict food intake . D. encourage the client to discuss the procedure with the surgeon .

validate what the client understands about the surgical procedure


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