a3

A nurse is preparing a client for an EEG. When the asks the nurse what this test does, which of the following responses should the nurse provide?

"An EEG records the electrical activity of your brain cells."

A nurse is caring for a client during the 72 hr following a cerebrovascular accident (CVA). Which of the following actions should the nurse take?

Elevate the head of the bed 25-30 degrees with the client in a neutral midline position

A nurse on an oncology unit is providing discharge teaching to an adolescent female client who received a bone marrow transplant for leukemia. Which of the following pieces of information should the nurse include in the teaching? (Select all that apply) a. "Take your temperature twice each day." b. "You may return to school if you feel strong enough." c. "It is important to wear shoes always." d. "Clean you toothbrush weekly with isopropyl alcohol." e. "Avoid using tampons."

a. "Take your temperature twice each day." c. "It is important to wear shoes always." e. "Avoid using tampons."

A nurse is preparing a client for an electromyogram (EMG). Which of the following statements indicates that the client understands the pre-procedure teaching? a. "This test will help my doctor know if my nerves are working correctly." b. "The doctor will be able to fix the problem with my arm during this procedure." c. "I cannot eat or drink for at least 10 hr before I have this procedure." d. "I will get enough sedation to put me to sleep for this procedure."

a. "This test will help my doctor know if my nerves are working correctly."

A nurse is preparing a client for cardiac catherization. Which of the following pieces of information should the nurse give the client before the procedure? (Select all that apply) a. "You'll have to lie flat for several hours after the procedure." b. "You'll receiving medication to relax you before the procedure." c. "You'll feel a cool sensation after the injection of the dye." d. "You'll have to keep your leg straight after the procedure." e. "You'll have to limit the amount of fluid you drink for the first 24 hrs."

a. "You'll have to lie flat for several hours after the procedure." b. "You'll receiving medication to relax you before the procedure." d. "You'll have to keep your leg straight after the procedure."

A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client? a. Acidosis b. Infection c. Hypertension d. Cardiac tamponade

a. Acidosis

A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (Select all that apply) a. Assign the client to a private room with negative pressure airflow. b. Add contact precautions to the clients plan of care. c. Wear an N95 respirator when entering the clients room. d. Ensure the clients environment provides 4 exchanges of fresh air per minute. e. Institute Protective environment precautions as soon as the client arrives on the unit.

a. Assign the client to a private room with negative pressure airflow. c. Wear an N95 respirator when entering the clients room.

A nurse is caring for a client who is postoperative following a parathyroidectomy to treat hyperparathyroidism. Which of the following lab values should the nurse expect to decrease as a therapeutic effect of the procedure? a. Calcium b. Sodium c. Potassium d. Phosphorus

a. Calcium

A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching? a. Chicken breast and corn on the cob b. Shrimp and rice c. Cheese omelet and turkey bacon d. Liver and onions

a. Chicken breast and CORN

A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document? a. Coarse crackles b. Wheezes c. Rhonchi d. Friction rub

a. Coarse crackles

A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active tuberculosis, was placed on airborne precautions, and is scheduled for a chest X-ray. The nurse should instruct the newly licensed nurse to take which of the following actions? a. Have the client wear a surgical mask. b. Wear a gown for protection from the clients infection. c. Ask the radiology staff to perform a portable chest X-ray in the clients room. d. Place an N95 respirator on the client.

a. Have the client wear a surgical mask.

A nurse is planning care for a client who has a deep partial-thickness and full-thickness thermal burn over 40% of his total body surface and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? a. Initial range of motion exercises b. Use clean technique to provide wound care c. Place the client on a low-protein diet d. Maintain the client on bed rest

a. Initial range of motion exercises

A nurse is admitting a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurse's priority? a. Initiate airborne precautions b. Administer antimicrobial therapy c. Tell the client that the infection will be communicable for 2-3 weeks from the start of medication therapy d. Teach the client about the manifestations of tuberculosis

a. Initiate airborne precautions

A nurse is caring for client who has chronic phantom limb pain following an above-knee amputation. Which of the following medication prescriptions should the nurse very with the provider? a. Meperidine b. Amitriptyline c. Gabapentin d. Propranolol

a. Meperidine

A nurse is examining the ECG of a client who is having acute myocardial infarction. The nurse should identify that the elevate ST segments on the ECG indicate which of the following alteration? a. Necrosis b. Hypokalemia c. Hypomagnesemia d. Insufficiency

a. Necrosis

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following lab results should the nurse anticipate as the cause of this ECG change? a. Potassium 2.8 mEq/L b. Digoxin level 0.7 ng/mL c. Hemoglobin 9.8g/dL d. Calcium 8.0 mg

a. Potassium 2.8 mEq/L

A nurse is checking the lab values of a client who has chronic kidney disease (CKD). The nurse should expect elevations in which of the following values? a. Potassium and magnesium b. Calcium and bicarbonate c. Hemoglobin and hematocrit d. Arterial pH and PaCO2

a. Potassium and magnesium

A nurse is caring for a client who has a TBI and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? a. The client rigidly extends his arms b. The client internally flexes his wrists c. The client curls into a fetal position d. The client internally rotates his legs

a. The client rigidly extends his arms

A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased ICP. Which of the following indicates that the medication is having a therapeutic effect.? a. The client's serum osmolarity is 310 mOsm/L b. The client's pupils are dilated c. The client's heart rate is 56/min d. The client is restless

a. The client's serum osmolarity is 310 mOsm/L

A nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2g sodium diet. Which of the following statements by the client indicates an understanding of the teaching? a. "I should use salt sparingly while cooking." b. "I can have yogurt as a dessert." c. "I should use baking soda when I bake." d. "I should use canned vegetables instead of frozen."

b. "I can have yogurt as a dessert."

A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? a. Absent pedal pulses b. Ankle swelling c. Hair loss d. Skin atrophy

b. Ankle swelling

A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? a. Estimation of burn injury b. Characteristics of the cough and sputum c. Extent of peripheral edema d. Amount of urine output

b. Characteristics of the cough and sputum

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should nurse expect? a. Pitting peripheral edema b. Crackles in the lung bases c. Jugular vein distention d. Hepatomegaly

b. Crackles in the lung bases

A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures of his tibia, ulna, and several ribs. The client is now disoriented to time and place and has a SaO2 of 87%. The nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? a. Hypovolemia shock b. Fat embolism syndrome c. Thrombophlebitis d. Avascular bone necrosis

b. Fat embolism syndrome

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? a. Tympanic temperature 38C (100.4F) b. PaO2 50mmHg c. Rhonchi d. Hypopnea

b. PaO2 50mmHg

A nurse is providing instructions about pursed-lip breathing for a client who has COPD with emphysema. This breathing techniques accomplishes which of the following? a. Increases oxygen intake b. Promotes carbon dioxide elimination c. Uses the intercostal muscles d. Strengthens the diaphragm

b. Promotes carbon dioxide elimination

A nurse is evaluating the injection site of a client who had a Mantoux skin test 48 hrs ago. The nurse finds 10mm of induration with slight redness. Which of the following conclusions should the nurse make? a. The client has active tuberculosis b. The client had an exposure to tuberculosis c. The nurse must re-evaluate the result in 24-hrs d. The test is negative for tuberculosis

b. The client had an exposure to tuberculosis

A nurse is teaching a client who has tuberculosis about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching? a. "I should take this medication with food." b. "I need to take a B-complex vitamin while using this medication." c. "I can expect this medication to turn my skin orange." d. "I can expect this medication to make my vision blurry."

c. "I can expect this medication to turn my skin orange."

A nurse in a clinic is providing teaching for a client who is scheduled to have a tuberculosis skin test. Which of the following pieces of information should the nurse include? a. "If the test is positive, it means you have an active case of tuberculosis." b. "If the test is positive, you should have another tuberculin skin test in 3 weeks." c. "You must return to the clinic to have the test read in 2 or 3 days." d. "A nurse will use a small Lancet to scratch the skin of your forearm before applying the tuberculin substance."

c. "You must return to the clinic to have the test read in 2 or 3 days."

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpitation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? a. Friction rub b. Crackles c. Crepitus d. Tactile fremitus

c. Crepitus

A client is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect? a. Hypokalemia b. Hypernatremia c. Elevated Hct d. Decreased Hgb

c. Elevated Hct

A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? a. Place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min b. Prepare the client for possible endotracheal intubation and mechanical ventilation c. Increase the oxygen flow and request an ABG determination d. Position the client supine and administer an antianxiety medication

c. Increase the oxygen flow and request an ABG determination

A nurse is assessing a client who has increased ICP and has IV mannitol. Which of the following findings indicates a therapeutic effect of this medication? a. Decreased blood glucose b. Decreased bronchospasms c. Increased urine output d. Increased temperature

c. Increased urine output

A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? a. The client will need intensive smoking-cessation education b. After surgery, the prognosis for clients with lung cancer is usually good c. Lung cancer usually metastasized before the client presents with symptoms d. Oxygen therapy is ineffective following a lobectomy

c. Lung cancer usually metastasized before the client presents with symptoms

A nurse in a providers office is assessing a client who stated he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? a. Pericardial friction rub b. Weight gain c. Night sweats d. Cyanosis of the fingertips

c. Night sweats

A nurse is assessing a client who has a positive tuberculin skin test. Which of the following findings indicates that the client has active tuberculosis? a. Rhinitis b. Air hunger c. Night sweats d. Weight gain

c. Night sweats

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? a. Metered-down inhaler b. Continuous passive motion machine c. Oral-nasal suction equipment d. External defibrillator pads

c. Oral-nasal suction equipment

A nurse is planning care for a client following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan? a. Position the client with her legs adducted b. Internally rotate the clients affected hip c. Place a pillow between the clients legs d. Instruct the client to avoid flexing her hip more than 95 degrees

c. Place a pillow between the clients legs

A nurse is caring for a client who has an impairment of cranial nerve II. Which of the following actions should the nurse perform to promote the client's safety? a. Initiate seizure precautions b. Ensure the client receives a soft diet c. Provide an obstacle-free path for ambulation d. Instruct the client to use lukewarm water when showering

c. Provide an obstacle-free path for ambulation

A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased ICP. This increase in ICP is due to which of the following? a. Decreased cerebral perfusion b. Leakage of cerebral spinal fluid c. Rigid skull containing cranial contents d. Brain herniated into the brainstem

c. Rigid skull containing cranial contents

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? a. First-degree frostbite b. Second-degree frostbite c. Third-degree frostbite d. Fourth-degree frostbite

c. Third-degree frostbite

A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hrs? a. Ineffective endocarditis b. Pericarditis c. Ventricular dysrhythmias d. Pulmonary emboli

c. Ventricular dysrhythmias

A nurse is assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect? a. Tonic-clonic seizures b. Report of a severe headache c. Weakness of the lower extremities d. Decreased level of consciousness

c. Weakness of the lower extremities

A nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure? a. "I'll drink less water so I don't have to catheterize myself too often." b. "I must use sterile technique for each catherization." c. "I should stop the catheterization when I have removed 150 mL of urine." d. "I will perform intermittent self-catheterization every 2 to 3 hr."

d. "I will perform intermittent self-catheterization every 2 to 3 hr."

A nurse is providing teaching to a client about transient ischemic attacks (TIAs). Which of the following pieces of information should the nurse include in the teaching? a. A TIA can cause irreversible hemiparesis b. A TIA can be the result of cerebral bleeding c. A TIA can cause cerebral edema d. A TIA can precede an ischemic stroke

d. A TIA can precede an ischemic stroke

A nurse is caring for a client who is recovering at home after inpatient treatment for burn injuries. To increase the protein density of the client's meals, which of the following recommendations should the nurse make to the client's caregiver? a. Use sour cream instead of plain yogurt b. Add honey to cooked cereals c. Use salad dressing in place of mayo d. Add chopped hard-boiled eggs to soups and casseroles

d. Add chopped hard-boiled eggs to soups and casseroles

A nurse is caring for a client who is suspected to have tuberculosis. Which of the following findings should the nurse expect? a. Recent weight gain b. High fever c. Rhinitis d. Blood-streaked sputum

d. Blood-streaked sputum

A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? a. Tracheostomy placement b. Thoracentesis c. CT scan of the chest d. Chest tube insertion

d. Chest tube insertion

A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome? a. Irregular cardiac rhythm b. Numbness in the hands c. Muscle cramps d. Facial edema

d. Facial edema

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take? a. Place the drainage system at the head of the clients bed b. Increase the suction to the chest drainage system c. Place the client on low-flow oxygen via nasal cannula d. Immerse the end of the chest tube in a bottle of sterile water

d. Immerse the end of the chest tube in a bottle of sterile water

A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? a. Obtain coagulation lab studies from the client b. Apply pneumatic compression boots to the client c. Request a referral for a speech-language pathologist d. Keep the client NPO

d. Keep the client NPO

A nurse is assessing a client who has acute kidney injury (AKI). According to the RIFLE classification system, which of the following findings indicates that the client has end-stage kidney disease? a. <0.5 mL/kg of urine b. No urine output for 12 hr c. No urine output without renal replacement therapy for 4 to 12 weeks d. No urine output without renal replacement therapy for more than 3 months

d. No urine output without renal replacement therapy for more than 3 months

A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect? a. Spasticity of the left foot b. Negative Babinski reflex c. Ocular hypertension d. Right-sided hemiplegia

d. Right-sided hemiplegia

A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hrs ago. Which of the following findings should the nurse report to the provider? a. Edema in the burned extremities b. Severe pain at the burn sites c. Urine output of 30 mL/hr d. Temperature of 39.1 C (102. 4F)

d. Temperature of 39.1 C (102. 4F)

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? a. The client is unable to speak b. The client's airway secretions is unable to speak c. The client coughs and expectorates a large mucous plug d. The nurse auscultates coarse crackles in the lung fields

d. The nurse auscultates coarse crackles in the lung fields

A nurse is preparing to administer a Mantoux skin test to a client. What is the purpose of a Mantoux skin test using purified protein derivative (PPD)? a. To identify if a client lacks immunity to tuberculosis b. To fluid out if a client has active tuberculosis c. To decrease the hypersensitivity of the client's reaction to PPD d. To identify if a client has been infected with Mycobacterium tuberculosis

d. To identify if a client has been infected with Mycobacterium tuberculosis