U World Questions

A nurse is caring for a college athlete who was recently diagnosed with moderate persistent asthma. Which common asthma trigger should the nurse teach this client to avoid? 1.) Latext-containing products 2.) Penicillin antibioitcs 3.) Secondhand cigarette smoke 4.) Strenuous physical activity

3.) Secondhand Cigarette smoke

The nurse is preparing to administer a continuous enteral feeding for a client with a nasogastric tube. Place the steps in the correct order. All options must be used 1.) Administer the prescribed feeding solution 2.) Elevate the head of the bed 30-45 degrees 3.) Flush the tube with 30 ml of water 4.) Identify the client using 2 identifier 5.) Validate tube placement

4, 2, 5, 3, 1

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply A.) Amenorrhea B.) Fluid and electrolyte imbalances C.) Heat intolerance D.) Presence of lanugo E.) Refusal to exercise F.) Weight loss of 25% below normal weight

A, B, D, F

The nurse plans discharge teaching for a client newly diagnosed with polycythemia vera. Which actions will the nurse include in the teaching plan? Select all that apply A.) Elevate the legs and feet when sitting B.) Increase dietary intake of foods rich in iron C.) Increase fluid intake during exercise and hot weather D.) Increase water temperature to reduce post-bath itching E.) Report swelling or tenderness in the legs

A,C,E

A client who suffered a burn injury has received fluid resuscitation and is now diuresing, indicating the end of the emergency phase. Which prescription is the highest priority at this time? A.) Administer enteral feedings at the return of bowel sounds B.) Assist the client in activites of daily living as tolerated C.) Contact the client's religious advisor for spiritual support D.) Educate the client's family about dressing and medicaitons

A.) Administer enteral feedings at the return of bowel sound

The charge nurse of the emergency department (ED) is mentoring a new registered nurse (RN). They are caring for a client who has a chest tube connected to wall suction for a pneumothorax. The client is being transferred from the ED to the telemetry unit. Which action by the new RN would cause the charge nurse to intervene? A.) Clamping the chest tube at the insertion site during the transfer B.) Disconnecting the suction tubing from the wall suction unit C.) Hanging the chest tube collection unit to the underside of the stretcher D.) Taping connections between the best tube and suction tubing

A.) Clamping the chest tube at the insertion site during the transfer Why? Clamping is contraindicated. This can cause air to go into the pleural cavity and then it has no way to get out. Can lead to tension pneumothorax and can be a potentially life-threatening condition

Which statement made by the client demonstrates a correct understanding of the home care of ascending colostomy? A.) I will avoid eating foods such as broccoli and cauliflower B.) I will empty the pouch when it is one-half full of stool C.) I will irrigate the colostomy to promote regular bowel movements D.) I will restrict my fluid intake to 2,000 milliliters of fluid a day

A.) I will avoid eating foods such as broccoli and cauliflower It is A because you have to identifiy and eliminate foods that cause gas and odor (broccoli, cauliflower, dried beans, brussels sprouts)

The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the nurse expect? Select all that apply. A.) Diarrhea B.) Difficulty breathing C.) Difficulty swallowing D.) Muscle weakness E.) Resting tremor

B, C, D,

A client with heart failure has gained 5lbs (2.26 kg) over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate? A.) 0.45% sodium chloride IV B.) Calcium gluconate C.) Furosemide D.) Sodium polystyrene sulfonate

C.) Furosemide Fasted way to decrease fluid within a patient is through excretion and furosemide helps with that. It is a loop diuretic

The nurse should call the primary health care provider to obtain a new prescription prior to administering which medication to a client with type 1 diabetes mellitus? A.) 10 units regular insulin IV push for blood glucose >250 mg/dl B.) 14 unites glargine insulin subcutaneous injection every night at 8:00 pm C.) 18 units aspart insulin subcutaneous injection 15 minutes before breakfast D.) 20 units NPH insulin IV push administered every morning at 7:00 AM

D.) 20 units NPH insulin IV push administered every moring at 7:00 AM

A nurse is teaching a parent of an infant about administration of an oral medication. What should be included in the teaching? Select all that apply A.) Add the medication to the bottle of formula before feeding B.) Direct liquid medication toward the inside of the infant's cheek C.) Hold the infant in a semi-reclining position during administration D.) Measure and administer the medication using an oral syringe E.) Open the infant's mouth by gently pinching the nose shut

B, C, D

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate? Select all that apply. A.) Decrease fluid intake to 1 glass with each meal and at bedtime B.) Encourage the client to bear down while attempting to void C.) Inspect the perineal area for evidence of skin breakdown D.) Measure postvoid residual volumes as prescribed E.) Tell the client to wait 30 seconds after voiding and then attempt to void again

B, C, D, E

A nurse is evaluating the teaching of weight reduction strategies to a client with obesity. Which of the following statements indicate that the client understands the teaching? Select all that apply A.) Fruit juice is a good substitute for soda B.) I will aim to lose 1-2 lbs per week C.) I will keep healthy snacks on hand in case I get hungry D.) I will skip breakfast to save calories for later in the day E.) I will take the stairs instead of the elevator

B, C, E

The nurse completes the preoperative assessment for a client scheduled for a total knee replacement. Which information should the nurse report to the health care provider (HCP_ as soon as possible before the surgery? A.) Has allergy to strawberries B.) Is experiencing burning on urination starting yesterday C.) Rates knee pain as a 9 on a 0-10 scale D.) Stopped taking celecoxib 7 days ago

B.) Is experiencing burning on urination starting yesterday

A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response? A.) "It destroys tumor cells and helps shrink the tumor." B.) "It prevents seizure development." C.) "It prevents blood clots in legs." D.) "It reduces swelling around the tumor."

B.) It prevents seizure development

A client is being admitted for a potential cerebellar pathology. Which task should the nurse ask the client to perform to assess if cerebellar function is within the defined limits? Select all that apply. A.) Identify the number 8 traced on the plam B.) Shrug the shoulders against resistance C.) Swallow water D.) Touch each finger of one hand to the hand's thumb E.) Walk heel-to-toe

D, E

The nurse is caring for a client with a fractured femur. Which nursing intervention is most effective in helping reduce the risk for fat emboli? A.) Administering prophylactic enoxaparn as prescribed B.) Frequent use of incentive spirometry C.) Minimizing movement of the fracture extremity D.) Use of an intermittent pneumatic compression device

C.) Minimizing movement of the fracture extremitiy FES or Fat Embolism Syndrome is when a long bone is fractures, pressure within the bone marrow leads to the release of fat globules into the bloodstream. These combine with platelets and can travel to the brain, lungs, and kidney, leading to small-vessel occlusion and tissue ischemia. Early stabilization of the injury and surgery as soon as possible to repair the long bone is recommended to reduce further injury to the soft tissue Nurse should minimize movement of the injured extremity to reduce the risk for fat emboli

A postoperative client is prescribed IV patient- controlled analgesia (PCA) with morphine. The client tells the nurse, "I am pushing the button, but I'm still having a lot of pain" What is the priority nursing action? A.) Administer a bolus dose B.) Notify the health care provider (HCP) to request a higher dose C.) Perform a thorough pain assessment D.) Reinforce the proper use of the IV PCA pump

C.) Perform a thorough pain assessment

When an unlicensed assistive personnel (UAP) assists a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidently falls over and cracks. The UAP immediately reports this incident to the nurse. What is the nurse's immediate action? A.) Clamp the tube close to the client's chest until a new chest drainage until is set up B.) Notify the health care provider (HCP) C.) Place the distal end of the chest tube into a bottle of sterile saline D.) Position the client on the left side

C.) Place the distal end of the chest tube into a bottle of sterile saline

A client is started on lisinopril therapy. Which assessment finding requires immediate action? A.) Blood pressure 129/80 mmHg B.) Heart rate 100/min C.) Serum creatinine 2.5 mg/dl D.) Serum potassium 3.5 mEq/L

C.) Serum creatinine 2.5 mg/dl

The nurse prepares to administer medication to a client. Which of the following client data are acceptable for use as client identifiers? Select all that aply A.) Date of birth B.) First and last name C.) Health care provider D.) Medical record number E.) Room number

A, B, D

A nurse is caring for a 3-month-old client with a new tracheostomy. Which findings would indicate a need for suctioning? Select all that apply A.) Audible gurgling B.) Heart rate 105/min C.) Increased irritabilty D.) O2 saturation 88% E.) Respiratory rate 30/min

A, C, D

The nurse cares for a client scheduled for a percutaneous left kidney biopsy as an outpatient. Which intervention should the nurse include in the client's post-procedure care plan? 1. Compare pre- and post-procedure BUN and creatinine levels 2. Insert and maintain the patency of an indwelling urinary catheter 3. Maintain prone position for at least 30 minutes 4. Monitor vital signs every 15 minutes for the first hour

4.) Monitor VS every 15 minutes for the first hour Why? To make sure they aren't bleeding or internally bleeding. Check for tachycardia, tachypnea and hypotension (all signs of hypovolemic shock or bleeding)

A pediatric client weighting 66 lbs is prescribed ibuprofen 5mg/kg by mouth every 6 hr PRN for fever. It is available as an oral solution of 20 mg/ml. How many milliliters (ML) of ibuprofen should be given to the client per dose? Record your answer using one decimal place.

7.5 ml

Which of these instructions is appropriate teaching for a 60-year-old woman? Select all that apply A.) Consume adequate sources of calcium and vitamin D and take supplements B.) Increases intake of food sources of iron and take supplements C.) Observe for unilateral leg swelling when taking hormone replacement therapy (HRT) D.) Remain upright for 30 minutes when taking bisphosphonate E.) Vaginal spotting after menopause if a common, insignificant sign of aging.

A, C, D

A postoperative client with obesity and diabetes mellitus has an abdominal incision and is at risk for poor wound healing. Which interventions should the nurse include in the plan of care to promote wound healing and prevent dehiscence? Select all that apply. A.) Administer docusate po Daily B.) Administer ondansteron IV PRN for nausea C.) Apply an abdominal binder D.) Implement caloric restriction to promote weight loss E.) Monitor blood sugar to maintain tight glucose control.

A, B, C, E

The nurse is teaching about cervical cancer prevention during a women's health conference. Which of the following factors should be taught as risks for cervical cancer? Select all that apply. A.) Human immunodeficiency virus (HIV) B.) Human papillomavirus (HPV) C.) Multiple sexual partners D.) Nulliparity E.) Sexual activity before age 18

A, B, C, E

A client who is intubated and on mechanical ventilation is receiving continuous enternal tube feedings at 30ml/hr via a small-bore nasogastric tube. Which action should the nurse take to prevent aspiration in this client? Select all that apply A.) Assess abdominal distention every 4 hrs B.) Check gastric residual every 12 hrs C.) Keep head of the bed at > or equal to 30 degrees D.) Maintain endotracheal cuff pressure E.) Use caution when administering sedatives

A, C, D, E

The nurse is caring for a client with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home. Which of the following actions by the nurses are appropriate? Select all that apply A.) Administers coagulation factor replacement IV push B.) Administers ibuprofen PO PRN for pain C.) Applies ice packs to the affected joint hourly for 15 minutes D.) Elevates the affected leg in the extended position E.) Performs neurologic assessment every 30 minutes for 6 hrs.

A, C, D, E

The nurse plans to administer 9:00 AM meds via the NG route to a client with an NG tube. The nurse contacts the primary health care provider (PHCP) to clarify which prescriptions that are contraindicated using this route? Select all that apply A.) Enteric- coated ibuprofen 200-mg tab B.) Extra-strength acetaminophen 500-mg tab C.) Metoprolol extended-release 50 mg tab D.) Sulfamethoxazole double-strength 800 mg tab E.) Tamsulosin 0.4- mg slow release capsule

A, C, E

A nurse teaches a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? Select all that apply. A.) Antibiotics can affect my INR value B.) I am going to eat more leafy greens C.) I will shoot for my INR value to be between 4 to 5 D.) I will take wafarin at the same time daily E.) If I miss a dose, I can double it on the following day.

A, D

The nurse is caring for a client who is taking riluzole for amyotrophic lateral sclerosis (ALS). The client asks, "there's no cure for ALS, so why should I keep taking this expensive drug? What is the nurse's best response? A.) It may be able to show the progression of ALS B.) It reduces the amount of glutamate in your brain C.) The case manager may be able to find a program to assist with cost D.) You have the right to refuse the medication

A.) It may be able to slow the progression of ALS

A client with cancer pain is prescribed oxycodone. Which teaching is most essential to help prevent long-term complications? A.) Teach the client how to assess blood pressure daily B.) Teach the client how to prevent constipation C.) Teach the client how to prevent itching D.) Teach the client how to prevent nausea

B) Teach the client how to prevent constipation

A 7-year- old client receives a scalp laceration to the back of the head while on a playground and the new nurse prepares to irrigate the wound. Which actions by the new nurse would require the experienced nurse to intervene? Select all that apply A.) Administers the prescribed analgesic 30 minutes before irrigating the wound B.) Cleanses the wound from the most to the least contaminated area C.) Obtains a 10-ml syringe and 27-gauge needle D.) Reviews the child's most recent immunization record E.) Uses continuous pressure to irrigate and repeats until drainage is clear

B, C

The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? Select all that apply. A.) Attaches an 18-gauge injection needle to a syringe for withdrawal of medication B.) Breaks the ampule neck away from the nurse's body to prevent injury from the glass C.) Disposes of the empty glass ampule in a sharps container D.) Injects air into the glass ampule prior to withdrawing the medication E.) Rests and steadies the needle on the ampule's outer rim to withdraw medication

B, C

The nurse cares for a client diagnosed with type 1 diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA). After checking the blood glucose, which prescription should the nurse implement first A.) Insert an indwelling urinary catheter for accurate output calculation B.) Obtain serum potassium level results and reports to the primary health care provider C.) Prepare an insulin drip for intravenous (IV) infusion as prescribed D.) Start an IV line and infused normal saline as prescribed

D) start an IV ine and infuse normal saline as prescribed Why? DKA= hyperglycemia Hyperglycemia causes osmotic diuresis, and clients are severly dehydrated. That's why you would give the fluids. You need to start the IV line first and give fluids before doing the insulin drip

A client with Alzheimer disease is found slumped over the lunch tray on the bedside table, coughing violently with emesis visible in the back of the throat. The client has a pulse of 135/min, respirations 32/min and o2 84%. The client also has circumoral cyanosis and decreased level of consciousness. Place the nurse's actions while awaiting the arrival of the rapid response team in priority order. All options must be used 1.) Administer 100% O2 by non-rebreather mask 2.) Assess lung sounds 3.) Notify the primary health care provider (HCP) 4.) Perform oropharyngeal suctioning 5.) Place client in high Fowler's position

2, 5, 4, 1, 3

After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning? 1.) Client rates leg pain as "7" 2.) Negative Homan Sign 3.) Prominent varciose veins bilaterally 4.) Right calf id 4cm larger than left calf

4.) Right calf is 4 cm larger than left calf

The nurse is preparing to suction secretions from the airway of an unconscious client whose lungs are mechanically ventilated with an endotracheal tube. Place the steps for suctioning the endotracheal tube in the correct order. All options must be used 1.) Advance catheter into the trachea 2.) Evaluate client tolerance and document 3.) Gently rotate the catheter while suctioning 4.) Hyperoxygenate the lungs (100% FiO2) 5.) Perform hand hygiene and don clean gloves 6.) Suction the oropharynx and perform oral care

5,6,4,1,3,2

A client is suspected of having Graves' disease (hyperthyroidism). Which signs and/or symptoms are expected to be present in this client? Select all that apply A.) Anxiety B.) Bradycardia C.) Dry skin D.) Heart palpitations E.) Protrusion of the eyeballs F.) Weight gain

A, D, E

A client with severe vomiting and diarrhea has a blood pressure of 90/70 mmHg and pulse of 120/min. IV fluids of 2 liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred? Select all that apply? A.) Capillary refill is less than 3 seconds B.) Pulse pressure is narrowed C.) Systolic blood pressure drops only when standing D.) Urine output is 360ml in 4 hrs E.) Urine specific gravity is 1.020

A, D, E

The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? Select all that apply A.) Call for help B.) Hold down the client's arms C.) Insert a tongue depressor to move the tongue D.) Prepare for suctioning E.) Turn the client on the side

A, D, E It isn't C because you shouldn't insert anything into the client's mouth especially if their teeth are clenched or mouth is closed.

The nurse in the intensive care unit cares for a client with primary adrenocortical insufficiency (Addison's disease). The client reports nausea and abdominal pain. The blood pressure suddenly drops from 120/74 mm Hg to 88/48 mm Hg, heart rate increases from 80 to 100/min, and the client appears confused. Which action should the nurse take first? A.) Administer as-needed dose of hydrocortisone intravenous (IV) push B.) Complete a head-to-toe assessment to identify any sources of infection C.) Document the findings in the client's electronic medical record D.) Take blood pressure sitting and standing to assess for orthostatic hypotension

A.) Administer as- needed dose of hydrocortisone intravenous (IV) push Signs of addisonian crisis include hypotension, tachycardia, dehydration, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion. Priority emergency management of addisonian crisis includes shock management, with fluid resuscitation using 0.9% normal saline and 5% dextrose; and administration of high-dose hydrocortisone replacement IV push.

The nurse educator is completing a staff education conference about prenatal carrier screening. Which statement by a participant indicates a correct understanding of the genetic inheritance for cystic fibrosis? A.) Both parents must be carriers of the abnormal gene for offspring to have the disorder B.) Female offspring are most often affected by the inheritance pattern of cystic fibrosis C.) If the female partner is a carrier, only male offspring will have the disorder D.) The inheritance pattern for cystic fibrosis does not skip generations

A.) Both parents must be carriers of the abnormal gene for offspring to have a disorder

The clinic nurse is reviewing the laboratory results of a 35-year-old client who reports fatigue for the last month. Based on the lab results, which additional clinical manifestations would the nurse expect? Lab results are Thyroid-stimulating hormone (TSH)8.6 µU/L (8.6 mU/L)0.4-4.2 µU/L (0.4-4.2 mU/L)Total triiodothyronine (T3)30 ng/dL (0.46 nmol/L)70-204 ng/dL (1.08-3.14 nmol/L)Free thyroxine (T4)0.2 ng/dL (2.57 pmol/L)0.8-2.7 ng/dL (10-35 pmol/L) A.) Bradycardia B.) Cold intolerance C.) Constipation D.) Hair loss E.) Warm, moist skin F.) Weight loss

A.) Bradycardia B.) Cold intolerance C.) Constipation D.) Hair loss The patient is exhibiting hypothyroidism because they have low T3 and T4 and have an increase in TSH. Some generalized slowing metabolic processes that is caused by hypothroidsm is -Weakness and fatigue -Weight gain -Bradycardia -Delayed deep tendon reflexes -Constipation -Cognitive slowing -Cold intolerance

The clinic nurse examines a client with tentative diagnosis of primary Sjogren's syndrome. Which finding observed by the nurse would most likely be associated with this syndrome? A.) Dry eyes and mouth B.) Low back stiffness C.) Multiple tender points D.) Thickening of the skin

A.) Dry eyes and mouth Sjogren's syndromei s an autoimmune condition. It causes inflammation of the exocrine glands, resulting in decreased production of tears and saliva and leading to dry eyes and dry mouth. Treatment w/ over-the-counter, preservative-free artifical tears can relieve eye dryness, burning, itching, irritation, pain and gritty sensation in the eyes. Wearing googles can protect the eyes from outdoor wind and dust. Dry mouth is treated with artificial saliva. Using a room humidifier and not sitting in front of fans, and air vents can also help.

The nurse inserts a urinary catheter into a female client who has not voided for 6 hrs. No urine is returned. What action should the nurse take next? A.) Leave the catheter in place and insert a new catheter higher up in the perineal area B.) Leave the catheter in place for 30 minutes and then recheck C.) Notify the prescribing health care provider that there is an obstruction D.) Remove the catheter and reinsert it at a position higher than the initial insertion.

A.) Leave the catheter in place and insert a new catheter higher up in the perineal area

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate? A.) The client has acute urinary retention B.) The client is confused and incontinent C.) The client is elderly and at risk for falls D.) The client is receiving intravenous diuretics

A.) the client had acute urinary retention

The nurse is caring for a client who has a laproscopic cholecystectomy 3 days ago. The client's WBC count has increased from 11,200/mm3 (11.2 X 10.9/L) to 14,600/mm3 (14.6x10.9L) over the last 24 hours. The nurse understands that which of the following assessment findings indicate potential infection? Select all that apply A.) Client rating left should pain as 4 on a scale of 0-10 B) Greenish-gray drainage noted on surgical dressing C.) Productive cough with thick, green sputum D.) Stiff abdomen with rebound tenderness on palpation E.) Warm, reddened area around the incision site

B, C, D, E Greenish gray drainage is not a normal finding, it should be purulent draining not greenish or gray The cough and sputum can indicate that the client may have contracted pneumonia or another type of respiratory infection

The nurse is assessing a group of clients in the community health clinic for metabolic syndrome. Which clietns exhibit features of the syndrome? Select all that apply A.) Female with a low-densitiy lipoprotein (LDL) level of 96 mg/dl (2/5 mmol/L) B.) Female with a waist circumference of 38 inches (96.5 cm) C.) Female with blood pressure of 148/90 mmHg D.) Male with a fasting blood glucose of 99 mg/dl (5.5 mmol/L) E.) Male with a triglyceride level of 201 mg/dl (2/3 mmol/L)

B, C, E

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority? A.) Apply anti-embolism stockings B.) Assist with early ambulation C.) Offer stool softeners D.) Provide low-fat foods

B.) Assist with early ambulation

A client has just returned from the cardiac catheterization laboratory for a permanent pacemaker placement. How should the nurse document the rhythm on the client's cardiac monitor? A.) Atrial paced rhythm B.) Atrioventricular paced rhythm C.) Biventricular paced rhythm D.) Ventricular paced rhythm

B.) Atrioventricular paced rhythm

The nurse is providing postoperative care to a client returning from a hemorrhoidectomy. Which action is the priority for the nurse to perform? A.) Administer docusate and teach the client to avoid straining during defecation B.) Give pain medications and instructions related to pain control C.) Remove the rectal dressing and check the client for bleeding D.) Teach the client how to self-administer a sitz bath 2-3 times daily.

B.) Give pain medications and instructions related to pain control Why? Hemorrhoids are caused by increased anorectal pressure. They may have rectal bleeding, pain, pruritius, and prolapse. The pain in the procedures is associated with it is due to spasms of the anal sphincter and is severe. Managment for post-hemorrhoidectomy client includes the followingL Pain relief: initially pain is managed with pain medications, including nosteroidal anti-inflammatory drugs and or acteaminophen Preventing constipation- encourage a high-fiber diet and adequate fluid intake. Administer a stool softener such as docusate as prescribed.

A nurse in the emergency department is titrating a continuous infusion of nitroglycerin to a client admitted for acute coronary syndrome. The client's vital signs, including blood pressure (BP), hear rate (HR), and pain level, are being monitored frequently. Which assessment findings indicate that the current rate of administration should be maintained? A.) BP 80/50 mmHg, HR 110/min; client reports pain is 0 out of 10 B.) BP 100/60 mmHg, HR 90/min; client reports pain is 3 out of 10 C.) BP 110/70 mmHg, HR 80/min; client reports pain is 0 out of 10 D.) BP 120/80 mmHg, HR 70/min; client reports pain is 5 out of 10.

C.) BP 110/70 mmHG, HR 80/min; client reports pain is 0 out of 10.

The nurse receives the assigned clients for today on a neurology unit. The nurse should check on which client first? A.) Client with history of head injury whose Glasgow Coma Scale (GCS) changes from 13 to 14 B.) Client with history of myasthenia gravis who has ptosis in the evening C.) Client with history of T2 spinal injury who has diaphoresiss, pulse 54/min and hypertension D.) Client with history of transverse myelitis with 2+ bilateral lower extremity muscle strength

C.) Client with history of T2 spinal injury who has diaphoresis, pulse 54/min and hypertension why? Autonomic dysreflexia (autonomic hyperreflexia) is a massive, uncompensated cardiovascular reaction by the sympathetic nervous system in a spinal injury of T6 or higher. Classic triggers are distended bladder or rectum. Classic manifestations include severe hypertension, throbbing headache, marked flushing. This is an emergency condition requiring immediate intervention. Management includes raising the head of the bed and then treating the cause

A nurse is preparing an educational presentation on herbal supplements for the local community center. Saw palmetto is one herbal medicine being discussed. Which audience participants would find this information beneficial? A.) Clients diagnosed with heart failure B.) Clients experiencing major depressive disorder C.) Elderly clients with benign prostatic hyperplasia D.) Perimenopausal clients experiencing hot flashes

C.) Elderly clients with benign prostatic hyperplasia Why? Saw palmetto is one such herbal preparation, and clients most often use it to treat benign prostatic hyperplasia Hawthorne extract is used to treat heart failure and in some countires is an approved treatment for this purpose St. John's wort has been used for centuries to treat depression. It may cause hypertension and serotonin syndrome when used with other antidepressants Black cohosh is an herbal supplement often used by perimenopausal clients experiencing hot flashes

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client has oliguria, dark amber urine, and muscle pain. The nurse should implement which prescription first? A.) ECG B.) IV morphine 2 mg C.) Normal saline bolus D.) Urine sample

C.) Normal saline bolus

A client is receiving a continuous heparin infusion and the most recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical incision and IV insertion sites. What intervention should the nurse implement? Select all that apply A.) Continue heparin infusion and recheck aPTT in 6 hrs B.) Prepare to administer vitamin K C.) Redraw blood for lab test D.) Review guidelines for administrating protamine E.) Stop infusion of heparin and notify the health care provider (HCP)

D, E

The charge nurse must assign rooms to 4 clients who are scheduled for admission. Which client has the highest priority for a private room assignment? A.) Client who is a know IV drug abuser who has osteomyelitis of the arm and chronic hepatitis C B.) Client with chronic obstructive pulmonary disease who has a latent tuberculosis infection C.) Client with diabetes mellitus and HIV infection who is in diabetic ketoacidosis D.) Client with pneumonia who has a positive methicillin-resistant Staphylococcus aureus nose culture.

D.) A client with pneumonia who has a positive methicillin-resistant staphylococcus aureus nose culture MRSA can be transmitted to others. If signs of infection are absent, treatment is not required. Colonized clients are at increased risk for infection with MRSA; if signs (ex: fever, wound drainage, purulent mucus) are present, treatment is required.

A 62- year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority? A.) Ask the client how long the leg has been tender and warm B.) Assess the electrocardiogram (ECG) for an ectopic beats C.) Check vital signs including pulse ox D.) Complete neurovascular assessment on lower extremities.

D.) Complete neurovascular assessment on lower extremities

The clinic nurse provides teaching for a client scheduled for a barium enema the next day. Which statement by the client shows a need for further instruction? A.) "I can expect chalky white stool after the procedure." B.) "I cannot eat or drink 8 hours before the procedure." C.) "I may have abdominal cramping during the procedure." D.) "I will avoid laxatives after the procedure."

D.) I will avoid laxatives after the procedure

An adult client is admitted with back pain and found to have a metastatic tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon. The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stay a few more days. Which is the most appropriate intital response by the nurse? A.) I understand your desire to leave, but it would be very risky B.) I will ask the palliative care nurse to talk with you to help clarify your care goals C.) I will let the HCP know that you want to be discharged and do everything I can to make it happen D.) Tell me more about your need to leave the hospital.

D.) Tell me more about your need to leave the hospital

A nurse is caring for a client on the first day postop after having minimally invasive direct coronary artery bypass (MIDCAB) grafting. The client thought that this surgery was suppose to have a much easier recovery and asks the nurse why it is so painful to take deep breaths. What is the best response by the nurse? A.) I am sorry you have so much pain. I'll go get your pain medication right now B.) Let me call the health care provider (HCP) to see if we can increase the dose of your pain medicine C.) Take deep breaths while splinting your chest with a pillow, and use you incentive spirometer every 2 hours. This will help your recovery D.) The overall recovery time is expected to be shorter, but initial postop pain can actually be higher with MIDCAB because the incisions are made between the ribs

D.) The overall recovery time is expected to be shorter, but initial postop pain can actually be higher with MIDCAB because the incisions are made between the ribs

A graduate nurse is reinforcing education to a pregnant client with hepatitis B who expresses concern about transmitting the virus to the newborn after birth. Which statement above newborn care made by the graduate nurse should cause the precepting nurse to intervene? A.) IM injections will be given after the newborn's bath to reduce exposure to bodily fluids during needle sticks B.) The newborn will receive both the hepatitis B vaccination and hepatitis B immune globulin injection after birth C.) You may safely intitate skin-to-skin contact after birth, which promotes bonding and keeps the newborn warm D.) You will need to formula feed your new born to reduce the risk of transmitting the virus via breast milk.

D.) You will need to formula feed your newborn to reduce the risk of transmitting the virus via breast milk I think the only transmittable disease where mom's aren't allowed to breast feed is HIV. Breastfeeding with Hep B has not been shown to affect newborn infection rates and is not contraindicated as long as the client's nipples are intact (Not bleeding or anything)

The registered nurse (RN) is providing nursing care with a licensed practical nurse and unlicensed assistive personnel. The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain. Three hours later, the client rates pain as a 9 out of 10 and requests pain medication. What is the most appropriate action for the RN to take? A) Adminsiter the hydromorphone B.) Ask the licensed practical nurse to administer the medication C.) Ask the unlicensed assistive personnel to take repeat vital signs D.) Contact the health care provider.

E.) Contact the health care provider Stat= med should be given immediately and only once. A new prescription for the med must be acquired before the dose can be repeated. The most appropriate action is to contact the health care provider to request an as-needed prescription for pain medication

The nurse has provided education for a client newly prescribed alprazolam for generalized anxiety disorder. Which client statement indicates that teaching has been effective? A.) Eliminating aged cheeses and processed meats from my diet is essential B.) I can skip doses on days that I am not feeling anxious C.) I will take my daily dose at bedtime D.) Using sunscreen is important as this drug will make me sensitive to sunlight

C.) I will take my daily dose at bedtime Why? Alprazolam is a benzodiazepines are commonly used antianxiety drugs. Benzo's cause sedation, which can interfere with dailytime activites. Giving the dose at bedtime will help the client sleep. MAOI's are the ones that you can't mix with tyramine which is found in aged cheese and processed meats

The nurse in the outpatient clinic is reviewing phone messages. Which client should the nurse call back first? A.) Client post kidney transplant who reports white spots in the oral cavity B.) Client with a history or mitral valve regurgitation who reports fatigue C.) Client with erythema and purulent drainage at the site of a spider bite D.) Client with hypertension who reports cold and nasal congestion

B.) Client with a history of mitral valuve regurgitation who reports fatigue Why? Mitral valve regurgitation is a result of a disrupted papillary muscle or ruptured chordae tendineae There is a back flow of blood from the left ventricle through the mitral valve int the left atrium. People who have this are usually asymptomatic but are instructed to report symptoms that may mean heart failure. These symptoms includes -Dyspnea -Orthopnea -Weight gain -Cough -Fatigue

The nurse is preparing a client who had a Roux-en-Y gastric bypass (RYGB) for discharge from the hosptial. What information should the nurse plan to include related to the prevention of dumping syndrome? A.) Meals should be small and low in carbs content B.) Fluids should be encouraged with each meal C.) Take a multivitamin with iron and calcium supplements daily D.) You will need to take your cobalamin injection monthly

A.) Meals should be small and low in carb content Why? To prevent dumping syndrome, clients should eat multiple small meals, eat a low-carbohydrate diet, and separate their consumption of food and fluids (Option 1). (Option 2) Clients should be taught to consume food and fluids at least 30 minutes apart, and the health care provider may limit total daily fluid consumption. Limiting fluids decreases distension and feelings of fullness. (Option 3) Iron-deficiency anemia is a common side effect after an RYGB as iron is absorbed in the duodenum and proximal jejunum. Taking supplements of iron and calcium can help with this problem but does not prevent dumping syndrome. (Option 4) The smaller gastric pouch decreases the amount of intrinsic factor made by the parietal cells in the stomach, which may cause cobalamin deficiency. The client will need parenteral or intranasal cobalamin replacement; however, this will not prevent dumping syndrome.

A client started a 24- hour urine collection test at 6:00 am. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 ml at 10:00 am by mistake but adding all specimens to the collection container before and after that time.What action should the nurse take? A.) Add 250 ml to the total output after the 24- hour urine collection is complete tomorrow morning B.) Discard urine and container, and restart the 24- hour urine collection tomorrow morning C.) Discard urine and container, have client void, add urine to new container , and then restart test D.) Relabel the same collection container, and change the start time from 6:00 am to 10:00 am

B.) Discard urine and container, and restart the 24-hour urine collection tomorrow morning

A client is being discharged after receiving an implantable cardioverter difibrillator. Which statement by the client indicates that teaching has been effective? A.) I'm not worried about the device firing now because I know it won't hurt B.) I will let my daugher fix my hair until my health care provider says I can do it C.) I will look into public transportation because I won't be able to drive again D.) I will notify my travel agent that I can no longer travel by plane

B.) I will let my daughter fix my hair until my health care provider says I can do it

The nurse is providing education to a client with a new prescription for progestin-only pills (POPS). Which statement about POPs is appropriate for the nurse to include? A.) If you begin vomiting any time within 24 hrs of taking the pill, take an additional pill B.) If you take your pill 3 or more hours after your usual time, use a backup contraceptive C.) In your pill pack, there are 21 days of progestin pills and 7 days of inactive iron pills D.) The use of POPs increases your risk of developing deep venous thrombosis

B.) If you take your pill 3 or more hours after your usual time, use a backup contraceptive

The nurse assesses a newborn with skin discoloration in the lumbar area, as shown in the exhibit what would be an appropriate action for then nurse to complete? A.) Assess the infant's hemoglobin, hematocrit, and platelet levels B.) Measure and document the size and location of the markings C.) Notify the health care provider of the markings immediately D.) Review the delivery record of evidence of traumatic birth

B.) Measure and document the size and location of the markings

The nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome will the nurse prioritize? A.) Acknowledges poor interpersonal skills B.) Identifies new coping mechanisms C.) Increases caloric intake to gain weight D.) Verbalizes sources of conflict and anger

C.) Increases caloric intake to gain weight Anorexia= very skinny, priority to restore caloric intake, promoting gradual weight gain and treating medical conditions

The nurse is assessing a client 15 minutes after initiating nitroglycerin infusion for suspected acute coronary syndrome. Which clinical finding is the priority? A.) The client reports a headache B.) The client reports feeling dizzy and lightheaded C.) The client reports feeling flushed D.) The client reports feeling nervous

B.) The client reports feeling dizzy and lightheaded why? Nitroglycerin is a vasodilator and relaxes the vascular smooth muscle. With people with acute coronary syndrome, it is administered by IV infusion to decrease preload and prevent spasm of coronary arteries, thereby increasing perfusion and o2 supply to the cardiac muscle. The nurse should follow up immediately if the client reports dizziness or lightheadedness, which may indicate profound hypotension.

The nurse admits an 81-year-old client with gastroenteritis. Admission vital signs are temperature 101 F (38.3 C), blood pressure 90/42 mmHg , pulse 118/min and respirations 32/min. Pulse oximetry shows 88%. The nurse suspects which of the following factors may be affecting accuracy of the pulse oximetry reading? A.) Dehydration B.) Elevated temperature C.) Hypotension D.) Tachypnea

C.) Hypotension Why? The sensor for pulse oximetry relies on adequate tissue perfusion, so low blood flow or decreased perfusion can decrease SPO2 readings. Although tachypnea can be associated with conditions that could cause decrease pulse oximetry readings, it is not an independent factor

The nurse is caring for an adult client at the clinic who asks the nurse to look at a "black skin lesion". What assessment findings would be a classic indication of a potential malignant skin neoplasm? Select all that apply A.) Blanches with manual pressure B.) Half of lesion is raised and half is flat C.) History of purulent drainage D.) Lesion is the size of a nickel E.) Various color shades are present

B, D, E

The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote to the client's comfort? Select all that apply. A.) Encourage adequate sodium intake B.) Place client in semi-fowler position C.) Place client in trendelenburg position D.) Provide alternating air pressure mattress E.) Use music to provide a distraction

B, D, E Why? Positioning the client in semi-fowler or fowler position can promote comfort, as this position can reduce the pressure on the diaphragm. The mattress helps with skin breakdown and music is good to distract the patient

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mmHg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? A.) Arterial blood gases (ABGs) B.) B-type natriuretic peptide (BNP) C.) Cardiac enzymes (CK-MB) D.) Chest x-ray

B.) B-type natriuretic peptide (BNP) Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea. (Option 1) ABGs will be helpful in determining the client's oxygenation status and acid-base balance but will not determine whether the cause of the dyspnea is cardiac or respiratory. (Option 3) CK-MB is a cardiospecific isozyme that is released in the presence of myocardial tissue injury. Elevations are highly indicative of a myocardial infarction but not specific for heart failure. (Option 4) A chest x-ray can show heart enlargement in the case of heart failure and may show infiltrations in the lungs. Pneumonia can also exacerbate COPD and can be confused with heart failure infiltrates. Chest x-ray is not as specific to heart failure as the BNP lab test.

The nurse is in the medication room preparing medications due at 1800 for a client who has an aortic valve replacement 5 days ago. Which action should the nurse implement first? A.) Assess the client's most recent potassium level B.) Check the client's INR C.) Measure the client's VS D.) Verify the client's name and date of birth at the bedside

B.) Check the client's INR

The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as the most appropriate to promote client nutrition? A.) Baked sweet potato, kale, yeast roll, water B.) Cheeseburger, apple, vanilla milkshake C.) Spaghetti with meatballs, fruit salad, milk D.) Vegetable soup, salad, dinner roll, iced tea

B.) Cheeseburger, apple, vanilla milkshake Why is this the answer? Need to give them energy- and protein dense foods that are easy to eat. like sandwiches shakes, burgers pizza. Basically a lot of junk food.

A client is receiving normal saline 75ml/hr and morphine sulfate via patient-controlled analgesia (PCA) bolus doses. The PCA and normal saline tubing are connected at the Y site. The nurse reviews a prescription from the health care provider to discontinue the normal saline. What is the most appropriate nursing action? A.) Change the rate of the normal saline to 10ml/hr B.) Clarify the prescription with the health care provider C.) Flush the IV with normal saline and then convert it to ta saline lock D.) Turn off the normal saline and disconnect it from the "Y" site

B.) Clarify the prescription with the health care provider

A nurse is discharging a client who has been hospitalized with streptococcal infective endocarditis (IE). Which statement by the client would indicate a need for further teaching? A.) I may need prophylactic antibiotics before dental work from now on B.) I should call my health care provider or 911 right away if I notice my speech is slurred C.) I shouldn't be concerned if I continue to have a fever at home D.) I will expect a home health nurse to give you IV antibiotics for several more weeks

C.) I shouldn't be concerned if I continue to have a fever at home

A client diagnosed with end-stage renal disease comes to the dialysis clinic for treatment. Which actions should the nurse take to prepare the client for hemodialysis? Select all that apply A.) Administer subcutaneous heparin to decrease clotting during dialysis B.) Administer the client's morning doses of carvedilol and lisinopril C.) Check the client's medical records to determine the last post-dialysis weight D.) Obtain a set of client vital signs and the client's current weight E.) Palpate the fistula in the client's arm for a thrill and auscultate for bruit

C, D, E It is not A because after the client is connected to dialysis , then IV heparin is added to the blood to prevent clotting but they do not receive a shot. It is not B because you shouldn't give BP meds before dialysis because it well get filtered out.

The clinic nurse is completing a health history for a client with suspected rheumatic fever (RF). Which question is most important for the nurse to ask to establish a diagnosis? A.) Do you typically take all your antibiotics when they are prescribed? B.) Has anyone in your family had rheumatic fever? C.) Have you recently had a streptococcal throat infection? D.) What has your temperature been over the past several days?

C.) Have you recently had a streptococcal throat infection Notes: Acute rheumatic fever Clinical features Major: -Joints (Migratory arthritis) -Carditis -Nodules (subcutaneous) -Erythema marginatum -Sydenham chorea Minor -Fever -Arthralgias -Elevated erythrocyte sedimentation rate/ C- reactive protein -Prolonged PR interval Late sequelae -Mitral regurgitation/stenosis Prevention- Penicillin for group A strept pharyngitis

A client with multidrug-resistant tuberculosis (MDR-TB) has a 1 month follow up visit after beginning medication therapy. The client states, "I've had really bad nausea and fatigue, but because my cough has already improved, I knew it would be alright to stop taking the medications". The nurse identifies which priority nursing diagnosis (ND) in this client's care plan? A.) Activity intolerance B.) Imbalanced nutrition, less than body requirements C.) Knowledge deficit of prescribed therapeutic regimen D.) Nausea

C.) Knowledge deficit of prescribed therapeutic regimen

The nurse cares for a client admitted with severe burns who is now on fluid resuscitation therapy. Which assessment findings would best indicate that fluid resuscitation has been successful? A.) Heart rate 89/min, blood pressure 99/52 mmHg B.) Potassium decrease from 5.7 mEq/L to 5.0 mEq/L ( C.) Urine output 31 ml/hr, respirations 20/min D.) Weight gain of 2.2 lbs (1kg) in last 8 hours and palpable pulses

C.) Urine output 31 ml/hr, respirations 20/min Why? Therefore, aggressive fluid resuscitation to correct hypovolemia is a priority. Adequate urine output (at least 30 mL/hr, or 0.5 mL/kg/hr) depends on adequate renal perfusion and is the greatest indicator that fluid resuscitation therapy has effectively restored tissue perfusion. (Option 1) Although stable vital signs (eg, systolic blood pressure ≥90 mm Hg, mean arterial pressure ≥65 mm Hg, heart rate <120/min) indicate client improvement, urine output is the greatest indicator of adequate fluid resuscitation. (Option 2) A decrease in serum potassium from 5.7 mEq/L to 5.0 mEq/L (5.7 mmol/L to 5.0 mmol/L) indicates that hyperkalemia is resolving but is not an indicator of tissue perfusion . (Option 4) Rapid increase in weight indicates that fluid shifts continue to occur and the kidneys are not eliminating properly. This could be a sign of fluid overload.

The nurse reviews the most current lab results of assigned clients. Which result should the nurse report to the health care provider immediately? A.) Client who has celluitis of the leg with a white blood cell (WBC) count of 13,000/mm3 B.) Client who has chronic kidney injury with a hematocrit of 28% and hemoglobin of 9g/dl C.) Client who has type 2 diabetes mellitus with a 2-hour postprandial serum glucose of 165 mg/dl

D.) Client who is 1 month post kidney transplant with a urinalysis showing WBC's and bacteria Why? Almost all post kidney transplant clients are prescribed immunosupressant drugs to help prevent organ rejection. This client's immunocompromised condition increases the risk for developing infection. Therefore, early recognition and prompt treatment of infection are critical to survival. The nurse should notify the health care provider (HCP) immediately of any signs or symptoms of an infection as well as abnormal urinalysis findings.

A client presents to the emergency department with a stab wound to the chest. The nurse asssess tachycardia, tachypnea, and sucking sound coming from the wound. Which of the following actions is priorty? A.) Administer prescribed IV fluids B.) Apply supplemental oxygen via nonrebreather mask C.) Assist the health care provider to prepare for chest tube insertion D.) Cover the wound with petroleum gauze taped on three sides

D.) Cover the wound with petroleum gauze taped on three sides Why? A traumatic or open pneumothorax= air rushes in through the wound with each inspiration. That is what causes the sucking sound (air fills the pleural space) The lungs are unable to expand, so the client becomes air hungry and goes into respiratory distress Priority is to add this dressing to prevent inward airflow while allowing air to escape the pleural space--> then they would get a chest tube in place. This is a temp fix until the chest tube.

The nurse provides post-procedure teaching for a female client who has cystoscopy as an outpatient. Which client statement indicates the need for additional instruction? A.) I can expect pink-tinged urine for at least 24 hours B.) I can take a warm bath and acetaminophen if I have discomfort or bladder spasms C.) I should expect frequency and burning when I urinate D.) I should expect to see blood clots in my urine for up to 24 hours

D.) I should expect to see blood clots in my urine for up to 24 hours Why is this the answer? Cystoscopy is when they insert a scope through the urethra into the urinary bladder with the client in the lithotomy position Some complications can be urinary retention, hemorrhage and infection. They need to notify the provider immediately if they see blood or blood clots or are unable to urinate or have abdominal pain. It isn't B because to help with the abdominal discomfort or bladder spasms they can take warm baths and can have a mild analgesic

A client is admitted with a pulmonary embolus. The nurse assess restlessness, one-word dyspnea and shortness of breath with activity, tachycardia, pleuritic chest pain, and severe anxiety. Arterial blood gases indicate respiratory alkalosis and hypoxemia. When initiating the care plan, the nurse should choose which nursing diagnosis as the highest priority? A.) Activity intolerance related to imbalance between oxygen supply and demand B.) Acute pain related to inspiration and inflammation of pleura C.) Anxiety related to fear of the unknown, chest pain, and dyspnea D.) Impaired gas exchange related to ventilation-perfusion imbalance

D.) Impaired gas exchange related to ventilation- perfusion imbalance

Which prescrption should the nurse question when caring for a hospitalized client diagnosed with acute diverticulitis? A.) Metronidazole 500 mg IV every 8 hrs B.) Nasogastric (NG) tube to suction C.) Nothing by mouth (NPO) D.) Prepare for barium enema in AM

D.) Prepare for barium enema in AM Diverticular disease of the colon occurs when saclike protrusions form in the large intestine. When diverticula become infected and inflamed, the client has diverticulitis. Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes the following: - IV antibiotic therapy - to cover the gram-negative and anaerobic organisms that reside in the colon and contribute to diverticulitis; these commonly include metronidazole (Flagyl) plus trimethoprim/sulfamethoxazole (TMZ) (Bactrim or Bactrim DS; Septra) or ciprofloxacin (Cipro) (Option 1) -NPO status - more acute cases require complete rest of the bowel (NPO status); less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet (Option 3) -NG suction - in severe cases of abdominal distention, nausea, or vomiting (Option 2) -IV fluids - prevent dehydration Bed rest You wouldn't do an Enema because it can increase intraabdominal pressure and increase peristalsis or can lead to perforation or rupture of the inflamed diverticula

The nurse is caring for a client with acute pancreatitis admitted 2 days ago. Which assessment finding is most concerning? A.) Blood glucose level for the past 24 hours are > or equal to 250 mg/dl B.) Client is lying with knees drawn up to the abdomen to alleviate pain C.) Five large, liquid stools that are yellow and foul-smelling D.) Temperature of 102.2 F with increaing abdominal pain

D.) Temperature of 102.2 F with increasing abdominal pain

The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required? A.) I need to have the entire house treated by pest control to ensure the bed bugs are gone B.) I should concentrate on alleviating scratching as it can cause further complications C.) My other family members and pets are at risk of bed bug bites D.) This must have happened because I did not was the bed sheets this week

D.) This must have happened because I did not wash the bed sheets this week

The nurse provides discharge instruction to a client one day after laparoscopic cholecystecomy. Which statement by the client indicated that further teaching is required? A.) I can resume a regular diet but will avoid fatty foods for several weeks after surgery B.) I can return to work within a week of surgery C.) I will report to the health care provider if my temperature is higher than 101F D.) Tomorrow I can remove the puncture site bandages and take a bath

D.) Tomorrow I can remove the puncture site bandages and take a bath

The home health nurse is following up with the parent of a Native American infant recently diagnosed with lactose intolerance. In accordance with principles of culturally competent care, what is the most important question for the nurse to ask the parent? A.) Do your other children have this condition? B.) How long did your infant have diarrhea C.) How often are you feeding the infant? D.) What do you think caused your infant's illness?

D.) What do you think caused your infant's illness?