120 Final Review
A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take?
Obtain a sputum culture.
A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?
Spironolactone
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?
Stopping the infusion
A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?
Give the child acetaminophen for discomfort.
A nurse is instructing a group of clients about nutrition and eating foods high in iron. The nurse should include that which of the following aids in the absorption of iron?
Vitamin C
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?
Wash her hands before and after contact with the client.
A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor this client for which of the following conditions?
Fungal infection
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)
Hypotension Absence of bowel sounds Weakened gag reflex
A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals. Which of the following responses should the nurse make?
"Taking the medication between meals will help you absorb the medication more eficiently."
A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? (Select all that apply.)
Assess legs for redness. Apply elastic compression stockings. Perform passive range of motion exercises.
A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?
Assess the cranial nerves
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
Assess vital signs
A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
Poor impulse control Rationale: A client who had a stroke involving the right cerebral hemisphere is likely to have personality changes, which can include impulsiveness, confabulation, and poor judgment.
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
Position the child side-lying.
A nurse is planning a menu for a client who has folic acid deficiency anemia. Which of the following foods should the nurse include as high in folate?
½ cup of asparagus
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
Generalized urticaria.
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?
"Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."
A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?
A lucid period followed by an immediate loss of consciousness
A client admitted to the medical-surgical floor reports new-onset itching of the trunk and groin. The nurse notes multiple reddened wheals on the chest, back, and groin. Which question should the nurse ask next?
"Are you taking any new medication?"
A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response?
"Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely."
A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?
"Have you had a recent influenza infection?"
A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?
"Heparin does not dissolve clots. It stops new clots from forming."
A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?
"I will clean the hearing aids with alcohol wipes."
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
Place the client on his side
A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?
Prothrombin Time (PT)
A nurse is caring for a client who has HIV. Which of the following laboratory tests should the nurse monitor to assess the effectiveness of therapy?
Quantitative RNA assay
A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching?
Race
The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?
Radial pulse in the left arm
A nurse is caring for an antepartum client who has iron-deciency anemia. When teaching the client about nutrition, the nurse should emphasize the need for an increased intake of which of the following foods?
Red meat and organ meat
A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings is a manifestation of a hemolytic transfusion reaction?
Report of lower back pain
A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV). He states, "I don't care what the doctors say, there is no way I can have HIV, and I don't need treatment for something I don't have." The nurse identifies that the client is experiencing which of the following types of crisis?
Situational
A nurse is teaching a client who is postpartum and has been diagnosed with iron deficiency anemia. Which of the following dietary recommendations should the nurse include in the teaching plan?
Spinach and beef
A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide?
Take the medication with orange juice to enhance absorption.
The nurse delegates the measurement of vital signs to an experienced unlicensed assistive personnel (UAP). Osteomyelitis has been diagnosed in a patient. Which vital sign would the nurse instruct the UAP to report immediately for this patient?
Temperature of 101 F (38.3 C)
After the nurse has performed a skin assessment on a recently admitted 19-year-old client, which finding is the highest priority to report to the healthcare provider?
Tenting of the skin on the forearms
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?
The client needs total nursing care
A nurse is setting goals for a client who has AIDS and is at the end of life. Which of the following are realistic goals?
The client will receive medication to minimize episodes of breakthrough pain.
A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching?
"I will monitor my husband for tilting his head forward when he swallows."
A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?
Place the client in a private room with a special ventilation system.
A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?
"I will take my medications at the first sign of an attack."
A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?
"Incorporate nonverbal cues in the conversation."
A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?
"Increasing my intake of foods containing trans-fatty acids can lower my risk."
A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching?
"Offer fluids to your child multiple times every day."
A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?
"Please ring for assistance when you wish to get out of bed."
A nurse is preparing a client who has AIDS for discharge. Which of the following statements should the nurse include in the discharge instructions?
"Prevent the spread of infection with good household cleaning practices."
A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following information should the nurse provide?
"Urine and other secretions might turn orange."
A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?
A phlebotomist who collects blood from clients who have HIV
A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?
A reddened area over the sacrum
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
A room with air exhaust directly to the outdoor environment
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?
A self-report pain rating scale
While auscultating a client's heart sounds, the nurse hears turbulence between the S and S heart sounds. The nurse should document this finding as which of the following?
A systolic murmur
A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of anti-tubercular medications. Which of the following information should the nurse include in the teaching?
A typical course of treatment involves 6 to 9 months of consistent medication use.
Which postoperative client is manifesting the most serious negative effect of inadequate pain management?
Develops venous thromboembolism related to immobility caused by pain and discomfort
A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?
Administer another nitroglycerin tablet.
A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?
Airborne
A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis?
Albumin
After the nurse performs a skin assessment on a 82-year-old new client in a medical-surgical floor, which finding is of most concern?
An irregular border is seen on a black mole on the scalp.
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?
Antiplatelet aggregate
A nurse is caring for a client who has HIV-1 infection and is prescribed zidovudine as part of antiretroviral therapy. The nurse should monitor the client for which of the following adverse effects of this medication?
Aplastic anemia
A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?
Apply a protective boot to the right ankle
A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function?
Apply downward pressure while the client shrugs his shoulders upward.
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
Apply intermittent suction when withdrawing the catheter.
A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client add to his diet?
Avocado
A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on intravenous rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse effects?
Body secretions turning a red-orange color
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
CD4-T- cell count 180 cells/mm3
A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?
Candidiasis
A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)
Check peripheral pulses in the affected extremity. Keep the client's hip and leg extended. Have the client remain in bed up to 6 hr.
A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the plan to nurse take?
Check the client's vital signs every hour during the transfusion.
A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take? (Select all that apply.)
Check vital signs before transfusion. Insert an IV with a 19-gauge needle. Check the expiration date of the blood product with a second nurse
A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia?
Chronic blood loss
The charge nurse in the Medical-Surgical unit that employs RNs, LVNs, and UAPs is planning care for a patient with a stage three sacral pressure ulcer. Which nursing intervention is best to assign to an LVN?
Cleaning and changing the dressing on the ulcer every morning
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?
Completing a dressing change
A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication?
Decreased blood pressure
A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood?
Elevated blood urea nitrogen (BUN)
A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?
Encourage the client to take small bites.
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
FLAG Abnormally prominent U wave
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
FLAG Establish the ability to communicate effectively
A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?
Flu-like symptoms and night sweats
A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the client to avoid while taking this medication?
Grapefruit juice
A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?
Hemorrhagic Stroke
A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?
Impaired sense of humor Rationale: A client who had a stroke involving the left cerebral hemisphere is likely to have language deficits, which include difficult using or comprehending language and difficulty writing. The nurse should expect a client who had a stroke involving the right cerebral hemisphere to have an impaired sense of humor.
A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?
Inability to recognize his family members
A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspect which of the following types of anemia?
Iron-deficiency anemia
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
It is primarily transmitted through direct contact with infected body fluids.
A nurse in a provider's office is assessing a client who has AIDS. The nurse notes that the client has multiple and widespread raised, purplish-brown skin lesions. The nurse should recognize that these findings indicate which of the following conditions?
Kaposi's sarcoma
A nurse is caring for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Which of the following laboratory tests should the nurse instruct the client will be required while on this medication regimen?
Liver function tests
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.)
Loosen restrictive clothing. Place a pillow under the client's head.
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?
Manifestations preceded by a severe headache
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?
Massaging her legs
A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?
Minimize environmental stimuli
A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply)
Night sweats Low grade fever Blood in the sputum
The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action?
Notify the provider of the client's allergy.
A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first?
Nucleic acid amplification test (NAAT)
A nurse is creating a plan of care for a child who has sickle cell anemia. Which of the following interventions should the nurse include in the plan?
Observe for indications of hypokalemia
A nurse is creating a plan of care for a child who has sickle cell anemia. Which of the following interventions should the nurse include in the plan?
Observe for indications of hypokalemia.
A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?
Pacemaker spikes before each QRS complex
A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?
Perform neurovascular checks with vital signs
A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse?
The nurse starts the transfusion of another unit of blood product
A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)
Troponin I Troponin T CPK Myoglobin
A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Turn the client's head to the side
A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Turn the client's head to the side.
A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme-linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?
Western blot analysis
A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
Yellow-green drainage on the surgical incision