Adult Health 1 Final Review

A 20-yr-old female patient who is being seen in the family medicine clinic for an annual physical examination reports being sexually active. The nurse will plan to teach the patient about

testing for Chlamydia infection.

The nurse is assessing the dorsalis pedis pulse of a client with lower extremity pitting edema. Using the graphic shown below, which letter would correspond to the correct anatomical location to assess the pulse? Enter A or B as your answer.

top of foot

The nurse is planning to teach an older adult client who is obese and was admitted with chronic stable angina. The client states, "I really thought this was it. The pain was so bad, that I thought for sure I was going to die." Which of the following would be an appropriate response by the nurse?

"Are you willing to make lifestyle changes to prevent this from happening again?"

The nurse is teaching a client who has a chlamydial infection about newly prescribed doxycycline. Which of the following should the nurse include in the teaching?

"Avoid prolonged exposure to direct sunlight."

The nurse in the community health clinic is providing teaching to a client diagnosed with irritable bowel syndrome (IBS). Which of the following information should the nurse include in the teaching?

"Behavioral therapy has proved to be beneficial for patients with irritable bowel syndrome (IBS)."

The nurse is collecting the health history of a client admitted to the medical-surgical unit. The client states "At midnight, I am supposed to be observing my monthly fast for my religion." Which of the following would be an appropriate statement by the nurse?

"Can you describe to me what occurs during your fast?"

The nurse is discussing alternative therapies with a client who reports difficulty sleeping and is taking prescribed warfarin. Which of the following would be appropriate to recommend to the client to assist with sleep?

"Devices that play white noise can help decrease background noise."

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?

"Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

The nurse is reviewing the medical record of an older adult client who has diabetes type 1. The nurse notes that the client's HgA1C has been steadily increasing over the past several years. When assessing the client, which statement by the nurse would be most appropriate?

"Have you been taking the insulin prescribed by your provider?"

The nurse is assessing a client who reports recent hair loss. The nurse notes localized patches of alopecia. Which of the following would be an appropriate response by the nurse? Select all that apply.

"Have you ever experienced hair loss before?" "When did the hair loss begin?" "Can you tell me how you style your hair daily?"

The nurse is evaluating the outcome of the treatment goals for a client with heart failure. Which of the following would be the best question for the nurse to ask from the nurse's POC?

"How has your energy level been?"

The home health nurse is visiting with a client who had a stroke and has moved in with their adult child. The nurse should suspect the client's adult child is experiencing caregiver stress if which statement is made?

"I am hoping to restart my exercise program soon."

The nurse is educating a client who had a right hip arthroplasty about how to use the prescribed patient-controlled analgesia (PCA). Which of the following statements by the client indicates that more teaching is required?

"I can designate someone to push the PCA button for me if I am asleep."

The nurse is assessing a client at the beginning of the night shift. The client states, "I am not sleeping well at night, so can you not come into my room so often?" Which of the following would be an appropriate response by the nurse?

"I can review your plan of care to combine my tasks."

The clinic nurse is collecting the sleep history of a client. Which statement by the client would indicate to the nurse the client is experiencing acute insomnia?

"I have been having trouble staying asleep for the last few weeks."

A female patient returns to the clinical with a recurrent urethral discharge after being treated for a chlamydial infection 2 weeks ago. Which statement by the patient indicates the most likely cause of recurrence in her infection?

"I haven't told my boyfriend about the infection yet"

The home health nurse is visiting an older adult client following a fall. Which of the following statements would indicate to the nurse the client is experiencing an abnormal response to aging?

"I often forget things, which is to be expected."

The nurse is caring for an older adult client who recently moved in with their adult child. Which of the following statements by the client would indicate to the nurse the client might be experiencing mistreatment?

"I recently added my daughter on to my bank account."

The nurse has reviewed discharge instructions with a client newly diagnosed with diabetes, type 1, about sick day rules. Which of the following statements would indicate to the nurse that the client understands the teaching? Select all that apply.

"I should check my urine for ketones twice each day." "I should drink sugar-sweetened beverages if I experience vomiting." "I should eat small meals of soup or gelatin six to eight times a day."

The nurse has taught a female client with acne vulgaris about newly prescribed isotretinoin. Which of the following statements by the client would indicate to the nurse more teaching is required?

"I should expect to feel some sadness when I first start taking the medication."

The nurse at the local health clinic is talking with a client diagnosed with gastroesophageal reflux disease (GERD) 6 months ago who is learning to manage the condition. Which of the following statements by the client would indicate appropriate management?

"I sleep using a 6-inch foam block instead of a regular pillow."

The nurse is assessing a client diagnosed with Addison's disease. Which of the following statements by the client is consistent with the disease?

"I tend to crave salty food all the time."

The nurse is speaking with the spouse of a client who has terminal cancer. Which of the following statements made by the client's spouse indicates appropriate coping?

"I try to set aside a few minutes to myself each day."

The hospice nurse is caring for a client with terminal pancreatic cancer who is receiving end-of-life care. The client states, "I do not want to eat or be fed." Which of the following would be an appropriate statement by the nurse?

"I understand your choice and will inform the healthcare provider."

The nurse has taught a client newly diagnosed with celiac disease regarding dietary management. Which of the following statements by the client would require the nurse to follow-up?

"I usually prepare oatmeal and eggs for breakfast."

After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective?

"I will call an ambulance if I still have pain after taking three nitroglycerin 5 minutes apart."

The nurse is educating a client with newly diagnosed asthma about preventing asthma attacks. Which of the following statements by the client would require follow up by the nurse?

"I will choose perfumes that are lightly scented."

The nurse is providing discharge teaching to a client following cataract surgery. Which of the following statements by the client would indicate to the nurse more teaching is required?

"I will expect to have some pain in the affected eye."

The nurse has taught a client who was newly diagnosed with diabetes, type 1, about symptoms of hypoglycemia. Which of the following statements by the client would indicate to the nurse that teaching was effective?

"I will feel confused"

The clinic nurse has taught a client with allergic rhinitis about managing symptoms. Which of the following statements by the client would indicate to the nurse teaching was effective?

"I will have carpets removed from the bedroom."

The nurse has taught a client with diabetes type I about exercise and glucose control. Which of the following statements by the client would indicate to the nurse more teaching is required?

"I will increase my daily exercise when ketones are present in my urine."

The nurse is evaluating teaching with a client who is receiving continuous subcutaneous insulin via an external insulin pump. Which of the following statements by the client indicates teaching was effective?

"I will still need to monitor my blood glucose readings closely"

The nurse has taught a client newly diagnosed with diabetes, type 1, about preparing and administering a prescribed dose of regular insulin and NPH insulin. Which of the following statements by the client would indicate to the nurse that more teaching is required? Select all that apply.

"I will use the 0.5 mL syringes because the line markings should be easy to read." "I should use the same body site every time I give myself an injection."

The nurse has completed teaching with a client about how to perform colostomy care. Which of the following statements by the nurse would best evaluate if teaching was effective?

"I would like you to show me how you will care for the colostomy."

The nurse is teaching a client who is scheduled to start radioactive iodine (RAI) therapy for hyperthyroidism. Which of the following information should the nurse include in the teaching? Select all that apply.

"If your mouth becomes dry and irritated you may gargle with a mixture of salt and baking soda several times per day." "Wash your laundry separate from others in your house to minimize their exposure to radiation." "You will need to avoid being close to any pregnant women while you are receiving the treatment."

The nurse is teaching a client who is receiving immunotherapy for severe allergies. Which of the following information should the nurse include in the teaching? Select all that apply.

"Immediately report any itching, sneezing or dizziness after receiving the dose" "After you receive the dose you will need to be observed for 20 to 30 minutes" "You should try to avoid whatever causes your allergies as much as possible" "You should be aware that you could experience a delayed reaction up to 48 hours after receiving a dose."

The nurse has taught a client how to apply heat therapy to an infected leg ulcer. Which of the following statements, if made by the client, would indicate to the nurse that more teaching is necessary?

"It is ok if I fall asleep while using the heat packs."

The nurse is preparing to administer prescribed subcutaneous enoxaparin to a client who requires self-administration of the medication at home. The client asks, "Can you show me how I will give myself the injection? I am worried if I will be able to do it." Which of the following would be an appropriate statement by the nurse?

"Let me walk you through the steps, you can ask questions while I show you."

The nurse in the clinic is teaching a client who presents with a serum total cholesterol of 275 mg/dL and is prescribed rosuvastatin. Which of the following information should the nurse include in the teaching?

"Make sure to report if you have any muscle pain or weakness."

The nurse is collecting the health history of a client admitted with generalized myalgia and chills. Which of the following statements by the client would indicate that the client has influenza?

"My joints hurt really bad"

The nurse is caring for a client with hypertension (HTN) who recently started taking prescribed lisinopril. Which of the following, if reported by the client, would require immediate follow up by the nurse?

"My lips seem puffy"

The nurse is assessing the nutritional status of an older adult client who lives alone. Which statement by the client would require follow up by the nurse?

"My neighbor takes me food shopping every week."

The nurse is collecting the health history of a client who has a BMI of 35kg/m2. Which of the following statements by the client would require follow up by the nurse?

"My spouse says that my snoring seems to have gotten worse."

The nurse is talking with a client who has human immunodeficiency virus (HIV) with an undetectable viral load. Which of the following statements by the client would require more teaching by the nurse? Select all that apply.

"Now that I am undetectable, I can begin using over-the-counter antacids again for my heartburn." "I am so happy that my partner is no longer at risk of getting the virus." "I look forward to being able to stop taking the HIV medications."

The nurse is performing discharge teaching with a client who is Asian. The nurse notes the client is looking down and nodding while the nurse is speaking. Which statement by the nurse would be appropriate?

"Once I am done with the teaching, I will provide you time to ask questions."

The nurse is teaching a client who was newly diagnosed with genital herpes about disease management. Which of the following statements by the client would indicate to the nurse the need for more teaching?

"Once my lesions are gone, I will not be contagious to my partners."

The nurse is assessing the sleep habits of a client who has a history of depression and reports insomnia. The client states, "I spend my time in bed during the day, but then I find it difficult to fall asleep." Which of the following would be an appropriate response by the nurse?

"Only use the bed when you feel sleepy."

The nurse is educating a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD) about symptom management. Which of the following statements should the nurse include in the teaching?

"Perform pursed-lip breathing to prolong exhalation."

The community health nurse is educating a group of older adult clients about preventing pneumonia. Which of the following information should the nurse include as the best way to prevent pneumonia?

"Receive a vaccination as often as recommended."

The nurse is teaching a client with hypertension (HTN) about newly prescribed diltiazem. Which of the following information should the nurse include in the teaching?

"Report to your healthcare provider if you experience any constipation or muscle cramping."

The nurse is teaching a client who has been newly prescribed drug therapy for the treatment of acquired immune deficiency syndrome (AIDS). Which of the following information should be a priority for the nurse to include in the teaching?

"Successful treatment is dependent on taking the prescribed medications as scheduled."

After bariatric surgery, a patient who is being discharged tells the nurse, "I prefer to be independent. I am not interested in any support groups." Which response by the nurse is best?

"Tell me what types of resources you think you might use after this surgery."

The nurse is educating a client with diabetes, type 2, about newly prescribed glipizide. Which of the following statements by the nurse best describes the action of glipizide?

"This medication will stimulate your pancreas to release insulin."

A nurse is caring for a client who had a left total knee replacement. The client states "I will not be able to play with my grandchildren again." Which of the following statements by the nurse would support the client to cope with the situation?

"What are some of the activities you like to do with your grandchildren?"

The nurse is preparing a client for a scheduled bone marrow biopsy. The client states, "The idea of this procedure is very stressful. How can you help me relax?" Which of the following would be the most appropriate statement by the nurse?

"What are your concerns that are causing these feelings?"

The nurse is caring for a client who exhibits mild itching and rash on both hands. The nurse notes erythema, edema and papules on both the client's hands. Which of the following questions would be most appropriate for the nurse to ask the client to help determine the cause of the skin condition?

"What do you do for work?" "When was the last time you washed your hands?"

A 40-yr-old obese woman reports that she wants to lose weight. Which question should the nurse ask first?

"What factors led to your obesity?"

The nurse is talking with a client at a public health clinic. The client asks, "The doctor said that my CD4+ count is 450. Is that good?" Which of the following responses should the nurse make?

"Your count is a bit low, and you are susceptible to infection."

After change-of-shift report, which patient will the nurse assess first?

A 40-yr-old man with continuous enteral feedings who has developed pulmonary crackles?

The nurse is caring for four clients who are at risk for coronary artery disease (CAD). Which of the following clients would have the highest risk?

A 68-year-old white, female client who has a family history of heart disease and her waist circumference is 65 cm.?

The nurse is assigned to four clients and identifies that which client has the highest risk for developing pressure ulcers?

A 72-year-old female weighing 82 lbs with stress incontinence and dementia.

The nurse manager is planning an educational in-service about managing stress for a group of new nurses. Which of the following should the nurse manager include in the teaching? Select all that apply.

A list of websites that offer different techniques.

The nurse is planning an education conference about fluid spacing. Which of the following should the nurse include as an example of third spacing?

Abdominal ascites

The nurse is caring for a client who is being treated for a suspected syphilis infection. Which of the following findings would indicate to the nurse the client is in the latent (early) stage of the infection?

Absence of symptoms

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment?

Absent bowel sounds

The nurse is performing a physical assessment of a client suspected of having an endocrine disorder. The nurse notes hyperpigmentation on the client's knuckles, elbows, and knees. The nurse should recognize the finding as a manifestation of which of the following?

Addison's Disease

The nurse is caring for a client who is having an acute severe asthma attack. Which of the following actions would be a priority for the nurse to take?

Administer a prescribed nebulizer beta-adrenergic

The nurse is caring for a client with severe allergies who is having skin testing. A few minutes after the intra-dermal injection of the allergen was given, the client reports having shortness of breath (SOB), feeling anxious and dizziness. Which of the following interventions should the nurse take first?

Administer prescribed epinephrine 0.3 mL IM.

The nurse is caring for a client who has a prescription for regular insulin to be administered before breakfast. The nurse notes that breakfast trays are delivered at 800am. After checking the client's glucose level at 700am, which of the following actions should the nurse take?

Administer the insulin at 730.

The nurse at a local health fair is planning to screen local residents for risk factors of obesity. Which of the following groups of residents should the nurse target? Select all that apply.

African American male and female Hispanic male Native American women

The nurse is admitting a client who has tuberculosis (TB) and a productive cough. Which of the following isolation precautions should the nurse implement for this client?

Airborne

The nurse has attended a conference about pain. Which of the following should the nurse identify as an example of visceral pain?

Appendicitis

The nurse is planning care for a client who is Native American and has had a prolonged hospitalization. Which of the following should the nurse include in the care that would meet this client's cultural needs?

Arrange for the client to be escorted outside daily.

The nurse is reviewing the medical record for a client with newly diagnosed psoriasis who has a history of dysplastic nevi. The nurse should question the healthcare provider about which of the following prescriptions?

Artificial phototherapy

The nurse notes tympany when percussing the abdomen of a client who reports feeling constipated. Which of the following actions should the nurse take?

Ask about the client's nutrition and elimination history.

The nurse is developing a care plan for a client who was admitted and newly diagnosed with diabetes mellitus, type 2 secondary to obesity. When planning goals for the client which of the following actions should the nurse take first?

Ask if the client is willing to make lifestyle changes.

A 75-yr-old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well as they used to." Which action should the nurse take first?

Ask the patient about what type of vision problems are being experienced.

The unlicensed assistive personnel (UAP) reports to the nurse that the client with diabetes, type 2, has a bedside glucose of 65 mg/dL. Which of the following should be a priority action by the nurse?

Assess LOC

The nurse is assessing a client for fluid status and notes the client's skin stays wrinkled for less than 3 seconds after pinching. Which of the following actions should the nurse take?

Assess the client for other signs of dehydration.

The nurse is caring for a client who is recovering from nausea and vomiting and is ready to advance the diet. Which of the following meal choices would be appropriate for the client?

Baked chicken and rice casserole

The nurse is assessing a client who is one day postoperative appendectomy and has refused to take prescribed pain medication. Which of the following findings would indicate to the nurse the client might be experiencing unrelieved acute pain?

Bladder distention

The nurse is caring for a client who had a colostomy created 4 hours ago. Which of the following postoperative findings would require immediate action?

Blanching and dark red colored stoma

The nurse is caring for a client who had a unilateral adrenalectomy 2 hours ago to remove a tumor. Which of the following would be a priority to assess during the immediate postoperative period?

Blood pressure

The nurse is collecting the health history of a client who reports recent vision changes. Which of the following reported by the client would indicate to the nurse the client is experiencing cataracts?

Blurry vision

The nurse is assessing the skin of a client who works outdoors. Which area of the body should the nurse inspect to determine the client's true skin color?

Buttocks

The nurse is assessing the extraocular muscle function of a client with a head injury using the six cardinal positions. Which of the following cranial nerves is the nurse assessing?

CN III, IV, VI

A client who is scheduled for a skin test informs the nurse that the client has been taking corticosteroids to help control allergy symptoms. Which of the following actions should the nurse take?

Cancel the test until the client is off the corticosteroids.

The nurse is monitoring a client who is receiving moderate sedation. Which of the following would best indicate to the nurse the client's ventilatory effort?

Capnography

The nurse is caring for a client who has a wound on the left arm. The nurse notes purulent drainage and a foul odor while changing the dressing. Which of the following actions should the nurse take next?

Check the client's complete blood cell (CBC) count

The clinic nurse is reviewing the medical records for a client with a history of melanoma with lymph node involvement. Which of the following yearly diagnostic testing should the nurse expect to be prescribed for this client?

Chest x-ray

The nurse is caring for a client admitted with shortness of breath, productive cough and is suspected of having pneumonia. The nurse should understand that which of the following diagnostic tests would be the priority for this client?

Chest x-ray

The home health nurse is conducting a home assessment for an older adult client. Which of the following, if observed by the nurse, would require the nurse to intervene?

Client using the wall for support

The nurse is performing the assessment of a client's abdominal incision and observes the protrusion of intestines from the incision. Which of the following actions should the nurse take first?

Cover the wound with sterile moistened towels.

The nurse is assessing the abdomen of a client and notes fragile skin with purple-blue striae across the abdomen. The nurse should recognize this finding as a manifestation of which of the following endocrine problems?

Cushings Syndrome

The nurse is caring for a client who is actively dying and is experiencing delirium. Which of the following would be an appropriate action by the nurse?

Decrease environmental stimuli.

The nurse is caring for a client who is newly diagnosed with diabetes type II. The nurse notes that the client has a knowledge deficit related to using a glucometer. Which action should the nurse take next when planning teaching for this client?

Determine if the client is ready to learn.

The nurse is providing discharge teaching to a client diagnosed with heart failure. Which of the following topics should be a priority for the nurse to teach?

Diet

The nurse is monitoring a client with a right lower lobe pleural effusion who is post thoracentesis one hour ago. Which of the following assessment findings requires immediate attention by the nurse?

Diminished breath sounds auscultated in the right lower base

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) and death is imminent. The client states, "I do not want to see a lot of visitors anymore. Just my parents and my sibling can come in for a while each day." Which of the following actions should the nurse take? Select all that apply.

Discuss the request with the parents and sibling, and suggest that they explain the client's decision to friends. Place a "no visitors" sign on the client's door.

The nurse is assessing a client with chronic pain who is receiving a prescribed opioid. Which of the following findings should be a priority to report to the healthcare provider?

Drowsiness

The nurse is providing teaching for a client diagnosed with a gastric ulcer regarding dietary management. Which of the following choices, by the client, from the breakfast menu would indicate a correct understanding of the teaching?

Dry wheat toast with water

The nurse is performing a respiratory assessment for a client with pneumonia. The nurse notes that the sound heard when percussing the lower lobes was medium-intensity pitch and duration. The nurse should document the finding as which of the following?

Dull

The nurse is assessing a newly admitted client diagnosed with left-sided heart failure. Which of the following findings should the nurse expect? Select all that apply.

Dyspnea Frothy, pink sputum Orthopnea Dry, hacking cough

The nurse is working with the licensed practice nurse (LPN) to care for a client with hypertension. Which of the following actions would be appropriate for the nurse to delegate to the LPN?

Educate the client about disease management.?

The nurse is preparing to administer a prescribed dose of influenza vaccination to a client. Which of the following allergies documented in the client's medical record should indicate a contraindication to administering the vaccination?

Eggs

The nurse notes that a client who was admitted with heart failure has jugular venous distention (JVD), when lying flat in bed. Which of the following actions should the nurse take next?

Elevate the head of the bed 45 degrees and assess the client again.

The nurse is teaching a client who is starting drug therapy for severe obesity. Which of the following information should be a priority when teaching the client?

Emphasizing that the drug will not work successfully without proper diet and exercise.

Which non-modifiable characteristics could precipitate a patient to malignant melanoma? Select all that apply.

Fair skin Blonde hair Previous family history

The nurse is checking a client's wet-to-dry dressing to determine if it needs changing and notes the current dressing is still moist. Which of the following actions by the nurse would be most appropriate?

Follow the current dressing change orders?

The nurse is performing the key diagnostic assessment steps for a client who is suspected of having an endocrine disorder. Which of the following laboratory tests should the nurse include? Select all that apply.

Glycosylated hemoglobin Thyroxine (T4) Thyroid stimulating hormone (TSH) Serum osmolality

The nurse is planning an education conference about autoimmune diseases. Which of the following diseases should the nurse include in the conference? Select all that apply.

Graves' disease Rheumatoid arthritis Celiac disease Multiple sclerosis Systemic lupus erythematosus

1The nurse has taught a client with newly diagnosed hypertension about the DASH diet. Which of the following food choices by the client would indicate to the nurse that more teaching is required?

Hamburger and salad

A 60-yr-old man who is hospitalized with an abdominal wound infection has been eating very little and states, "Nothing on the menu sounds good." Which action by the nurse will be most effective in improving the patient's oral intake?

Have family members bring favorite foods.

The nurse is reviewing the laboratory results for a client who has been managing diabetes, type 1 at home. Which of the following results would best indicate if treatment has been effective?

Hemoglobin A1C 6.0%

The nurse is assessing a client's genetic risk for endocrine disorders. The nurse should ask the client if any relatives have a history of which of the following endocrine disorders? Select all that apply.

Hypothyriodism Diabetes mellitus Cushings disease Grave's disease Myxedema

The nurse is reviewing the prescriptions for a client reporting acute pain who has a history of renal insufficiency. Which of the following nonopioid analgesic medications should the nurse identify as contraindicated for this client?

Ibuprofen

The nurse is caring for a client with conductive hearing loss. The nurse should assess the client for which of the following? Select all that apply.

Impacted cerumen Otosclerosis Otitis Media

The nurse is providing care for a client who is experiencing a type I hypersensitivity reaction. Which of the following would be the best action for the nurse to take?

Implement emergency treatment for anaphylaxis

The nurse is assessing a client diagnosed with upper gastrointestinal bleeding. Which of the following assessment findings should the nurse expect?

Increased heart rate

The nurse is caring for a client who had an esophagogastroduodenoscopy (EGD) one hour ago. Which of the following findings would indicate the client is experiencing perforation?

Increased temperature

The nurse is obtaining an admission history from a client with Guillain-Barre syndrome. Which of the following should the nurse expect to find in the client's history?

Influenza virus 3 weeks ago

The home health nurse is reviewing the daily blood glucose levels of a client with diabetes, type 1, who receives prescribed NPH insulin morning and evenings and lispro sliding scale with meals. The nurse notes the client experiences hyperglycemia daily around 6am. Which of the following would be the best action by the nurse?

Instruct the client to check the blood glucose level at 2am and record results for one week.

The nurse is assessing a client's thyroid using an anterior approach. Which of the following would be appropriate instructions to give the client during the assessment?

Instructing the client to swallow

The hospice nurse is assessing a client who is actively dying. Which of the following should the nurse identify as a final finding at end of life?

Loss of hearing

The nurse is reviewing the medical record for a client with hearing loss who communicates by reading lips and sign language. Which procedure would require the nurse to do additional teaching to adequately prepare the client?

MRI?

The nurse is caring for a client who has a prescription for the antacid magnesium hydroxide/aluminum hydrate (Maalox). Which of the following serum laboratory findings should the nurse check before administering the medication?

Magnesium

The nurse is caring for a client who speaks Spanish and has a certified interpreter at the bedside. Which of the following actions would be appropriate for the nurse to take when discussing care with the client?

Maintain eye contact with the client.

The nurse is caring for a client who is 2 hours post-operative from a tracheostomy. Which of the following would be a priority for the nurse to have at the bedside?

Manual resuscitation bag

The nurse is performing a skin assessment on a client who is newly admitted to the unit. The nurse notes an area on the client's

Measure the area and note any drainage

Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)?

Minimizing sun exposure reduces risk for future BCC.

The nurse is assessing the visual acuity of a client during a routine physical. The client states, "I noticed that I am having trouble seeing things in the distance when I drive." The nurse should suspect the client is experiencing which of the following?

Myopia

The nurse notes the client's potassium level is 6.0 mEq/L. Which of the following actions should the nurse take?

Notify the healthcare provider

The nurse is assessing a client who had a total thyroidectomy 24 hours ago. The client is reporting a tingling feeling around the mouth and in the fingers and toes. Which of the following actions should the nurse take?

Obtain a prescription to check the client's serum calcium.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who states, "I have had diarrhea for a week, and I have not had an appetite because I am so tired." The client's medical history shows a significant decrease in lean body mass since the client's last admission. Which of the following actions should the nurse take first?

Obtain the client's diet history and assess factors that interfere with the client's oral intake.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving prescribed low-flow oxygen 2L/min via nasal cannula. Which of the following findings would indicate to the nurse that the treatment needs to be revised?

PaO2 level 55%

The nurse is assessing a client who is postoperative open reduction internal fixation for a right femur fracture. Which of the following findings would be the best indication to the nurse that the client is experiencing complex regional pain syndrome when assessing the skin of the affected limb?

Pallor

A 61-year-old female patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL (normal is 8.5-10.2mg/dL). The nurse will anticipate the need to teach the patient about testing for which levels?

Parathyroid hormone

Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider?

Patient stopped taking the medication 2 days ago.

After receiving change-of-shift report, which patient should the nurse assess first?

Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes.

The nurse performed a nutritional screening for a newly admitted client and found the client is at risk for poor nutrition. Which of the following actions should the nurse take next?

Perform a full nutritional assessment.

The nurse is preparing for the admission of a client with severe diarrhea who tested positive for Clostridium difficile (C. diff). Which of the following actions should the nurse include in the preparation?

Place a blood pressure cuff and stethoscope in the room?

The nurse is concerned that the client's midsternal wound is at risk for dehiscence. Which of the following interventions would help prevent this complication?

Placing a pillow over the incision site when the client is deep breathing or coughing

The nurse is assessing a client who reports chest pain with inspiration. The nurse notes a friction rub when auscultating breath sounds. Which of the following should the nurse suspect the client is experiencing?

Pleurisy

The nurse is planning care for a client who is newly diagnosed with early chronic human immunodeficiency virus (HIV). Which of the following prescribed prophylactic measures should the nurse include in the client's plan of care? Select all that apply.

Pneumococcal vaccine Influenza vaccine Hepatitis B vaccine

The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding?

Press firmly on the lesion

The nurse has educated a client who is newly diagnosed with hypertension about dietary restrictions. The client who is visually impaired, has requested a written copy of the education. Which of the following actions should the nurse take? Select all that apply.

Provide the instructions in a large print. Use pictures on the instructions.

The nurse is obtaining the health history from a client who was admitted with gastritis. The nurse should ask about which of the following that could be the cause of the gastritis? Select all that apply.

Psychological stress Daily consumption of alcohol Family history of Helicobacter pylori (H. pylori) Over-the-counter medication use like aspirin or ibuprofen

The nurse is caring for a client with diabetes, type 1, who is experiencing nausea and vomiting, abdominal pain, Kussmaul respirations, and fruity-scented breath. Which of the following actions by the nurse should be a priority?

Rapidly administering prescribed 0.9% normal saline intravenous fluids.

The nurse is caring for a client with diabetic ketoacidosis who has a prescription for intravenous infusion of insulin. Which of the following insulins should the nurse anticipate administering to this client?

Regular

A patient is extremely anxious about having a biopsy on a femoral lymph node. Which relaxation technique would be the best choice for the nurse to facilitate during the procedure?

Relaxation breathing

The nurse is caring for a client with the following arterial blood gas (ABG) results; pH 7.48, PaCO2 30, HCO3 23, PaO2 90. The nurse should recognize the results as which of the following?

Respiratory alkalosis

The nurse is assessing a client admitted with an upper respiratory infection. Which of the following findings is an early indication of hypoxia?

Restlessness

The community health nurse is preparing an educational conference for a group of older adult clients about illness prevention. Which of the following teaching strategies would be most appropriate for the nurse to use with these clients?

Role playing?

The nurse is reviewing the laboratory data for a client with a history of hypertension who is taking prescribed hydrochlorothiazide. Which of the following results would indicate to the nurse that the client's treatment should be revised?

Serum potassium 5.5 mEq/L

The nurse in the emergency department is monitoring the laboratory results of a client who presents with confusion and vomiting. The spouse told the nurse that the client has not been eating well lately. Which of the following laboratory findings would explain the client's presenting symptoms?

Serum sodium level 120 mEq/L

The nurse is preparing to suction a client who has a tracheostomy and audible rhonchi. Place the steps below, in the correct sequence of actions, the nurse should take. All options must be used.

Set up suction Sterile gloves (one hand sterile, one hand clean) Check catheter function Hyperoxygenation of patient Insert suction catheter without suction Withdraw suction catheter with intermittent suction rotating the catheter

The nurse is implementing nutritional interventions for a client with pneumonia. Which of the following should the nurse include in the plan of care for this client?

Small, frequent meals

An older patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action is most appropriate for the nurse to take?

Speak normally but more slowly.

The nurse is collecting the health history from a client who reports night sweats, hemoptysis and had a recent exposure to tuberculosis (TB). Which of the following diagnostic tests should the nurse expect to be prescribed for this client to confirm the diagnosis of TB?

Sputum culture for acid-fast bacillus

The nurse inspecting a client's pressure ulcer notes full-thickness tissue loss and visible subcutaneous fat. The nurse should recognize the pressure ulcer as which of the following stages?

Stage III

The nurse is caring for a client with a wound that requires a skin graft. Which of the following types of debridement should the nurse prepare the client to receive in order to prepare the wound bed for the graft?

Surgical

During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions?

Symmetric

The nurse is preparing to measure the blood pressure for a client with a history of hypertension. Which of the following actions should the nurse take?

Tell the client to keep the feet flat on the floor.

The nurse is reviewing the plan of care for a group of assigned clients. Which of the following clients should the nurse identify as having the highest risk for developing hyperglycemic hyperosmolar syndrome (HHS)?

The 55-year-old client with diabetes, type 2, who has pneumonia.

The nurse is monitoring a client who is experiencing hypertensive crisis and is receiving prescribed intravenous infusion of antihypertensive medication. Which of the following findings would indicate the client is experiencing a complication?

The client appears lethargic

The clinic nurse is assessing the level of risk for complications of a client with pneumonia. Which of the following findings would indicate to the nurse the client will require admission to the hospital for treatment? Select all that apply.

The client is alert and oriented x 1 to self The client has a BUN level of 24 mg/dL The client has a respiratory rate of 33 breaths per minute

The nurse is caring for a 76-year-old client who had a total knee replacement (TKR) one hour ago. Which of the following information should indicate to the nurse that the client has a high risk of developing a pressure ulcer? Select all that apply.

The client is receiving prescribed intravenous (IV) pain medication The client's age The client is alert and oriented x 1 Immobility related to the surgery

The nurse is evaluating the outcome for a client who was discharged with the goal of maintaining a well-balanced diet after being hospitalized for malnourishment. Which of the following would be the best indicator of the client achieving the goal?

The client provides the nurse with a food diary from the past two weeks.?

The nurse is developing the plan of care for a group of assigned clients. Which of the following clients should the nurse identify as having the highest risk of developing aspiration pneumonia?

The client who had a CVA

The community health nurse is reviewing the medical records of a group of clients. Which of the following clients should the nurse identify as having the highest risk for health disparities?

The client who is a high school graduate and recently disclosed being gay.

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse indicates that this identified problem is resolving?

The patient asks how to clean the tracheostomy stoma and tube.

A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching?

The patient uses a tanning booth weekly

A patient who has fibromyalgia reports pain at level 7 (0 to 10 scale). The patient tells the nurse, "I feel depressed because I ache too much to play golf." Which patient goal has the highest priority when the nurse is developing the treatment plan?

The patient will be able to play a round of golf.

The nurse is assessing a client's hearing using the Weber test. Which of the following if reported by the client would indicate sensorineural hearing loss?

The sound is heard louder in the unaffected ear

The nurse is assessing the pulse of a client and notes the pulse to feel weak, and easily disappears with pressure during palpation. The nurse should document the client's pulse as which of the following?

Thready

The nurse is assessing a newly admitted client for risk of hyperphosphatemia. The nurse should ask the client about which of the following when obtaining the medical history?

Thyroid surgery

The nurse is caring for a client who has a dry wound on the left leg. Which of the following types of dressings would be appropriate for the nurse to apply? Select all that apply.

Transparent film Hydrogels Hydrocolloids

The community health nurse is identifying resources for a group of older adult clients who live in a rural community. Which of the following should the nurse identify as the priority resource for these clients?

Transportation services

The nurse is collecting the health history for a female client who is reporting vaginal itching and a yellow-green discharge. Which of the following should the nurse suspect the client is experiencing?

Trichomonas

Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin that could cause cancer?

Try to stay out of the direct sun between the hours of 10 AM and 2 PM.

The nurse is assessing a client with pertussis. Which of the following findings should the nurse expect to observe with this client?

Uncontrollable, whooping cough

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Appropriate instructions for the patient include

notify the health care provider if nausea develops.

The nurse is reviewing the ABG results for a client who was admitted with chronic obstructive pulmonary disease (COPD) exacerbation. Which of the following results should indicate to the nurse that the client's condition is getting worse?

pH 7.28 CO2 60 HCO3 26 PaO2 55