Adult health F exam prep u

The nurse's discharge teaching plan for the client with heart failure should emphasize the importance of:

-obtaining daily weights at the same time each day.

A client with peptic ulcer disease wants to know nonpharmacologic ways that he can prevent recurrence. Which of the following measures would the nurse recommend? Select all that apply.

Avoidance of alcohol Smoking cessation Following a regular schedule for rest, relaxation, and meals

A group of nursing students studying platelet disorders lists which of the following potential causes of thrombocytopenia that affect bone marrow function? Select all the apply.

Chemotherapy Aplastic anemia Radiation therapy Leukemia

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

Elevated blood pressure

While being on subcutaneous heparin injections for deep vein thrombosis during her latter pregnancy, a patient begins to experience major side effects. Her OB physician has called in a specialist who thinks the patient is experiencing heparin-induced thrombocytopenia. The nurse should anticipate which of the following orders?

Immediately discontinue the heparin therapy.

An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder?

Metabolic alkalosis

A nurse is giving a client barium swallow test. What is the most important assessment a nurse would make to ensure that a client does not retain any barium after a barium swallow?

Monitoring the stool passage and its color.

Which dysrhythmia is common in older clients?

Sinus bradycardia

A lower-than-normal number of platelets or thrombocytes

Thrombocytopenia

Which client is at risk for pulmonary embolism? A client with:

deep vein thrombosis

common warning signs MI

sensation of chronic indigestion or heartburn

To effectively prevent or manage metabolic syndrome, what should the desired blood lipid profile include? Select all that apply.

• Low triglycerides • High HDL cholesterol • Low LDL cholesterol

Which is a clinical manifestation of cholelithiasis?

-Clay-colored stools

A patient has been receiving intramuscular injections of hydroxocobalamin as treatment for pernicious anemia. Which statement by the patient indicates that he understands the therapy?

-"I will need these injections monthly for the rest of my life."

A deep vein thrombosis (DVT) results in vascular vasodilation, local tissue congestion, and increased capillary permeabilty. The nurse would expect to see which of the following body responses in a client with a DVT?

-Erythema and pain

A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate?

-Gastroesophageal reflux disease

Which is a characteristic of right-sided heart failure?

-Jugular vein distention

Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply.

A. Avoid surface bumps because the skin is prone to injury. B. Prevent DVT because of risk of pulmonary emboli. D. Walk daily as a good exercise. E. Perform foot/leg exercises and walk around the airplane cabin on long flights. F. Check urine for bright blood and a dark smoky color.

The nurse is assisting the physician with a procedure to remove ascitic fluid from a client with cirrhosis. What procedure does the nurse ensure the client understands will be performed?

Abdominal paracentesis

The nurse is providing nutritional instruction to the client diagnosed with hypovolemia. Which would the nurse emphasize as something to avoid?

Beverages with alcohol or caffeine

A client comes to the clinic and informs the nurse that he is there to see the physician for right upper abdominal discomfort, nausea, and frequent belching especially after eating a meal high in fat. What disorder do these symptoms correlate with? -

Cholethiasis.

A patient presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?

Decompensation

Which of the following mitral valve conditions generally produces no symptoms?

Prolapse

Which of the following clients is at highest risk for peptic ulcer disease?

-Client with blood type O

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?

-Clients may observe that rings, shoes, or clothing have become tight.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?

- Ask the health care provider to order a basic metabolic panel. (Generalized weakness is a manifestation of hypokalemia.)

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L. Which prescribed therapy should the nurse question?

- Infuse 5% dextrose in water at 125 mL/hr

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?

- Serum calcium is 18 mg/dL. (the serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias).

You are assessing a 6-year-old little girl in the emergency department (ED) who was brought in by her mother. She was stung and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child?

- She is having an allergic reaction and going into anaphylactic shock.

Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply.

- Smoking - Overweight - Lack of exercise

A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?

-Level of consciousness (LOC)

A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When coaching a client about behaviors to maintain health, the nurse determines that the client has understood the nurse's instructions when the client states a willingness to:

-lose weight by following a reduced calorie, balanced diet.

The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client states:

I have learned some relaxation strategies that decrease my stress."

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock?

Distributive. -Three types of distributive shock are neurogenic, septic, and anaphylactic shock.

A client with a myocardial infarction develops acute mitral valve regurgitation. The nurse knows to assess for which manifestation that would indicate that the client is developing pulmonary congestion?

Shortness of breath

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement?

"I sleep on three pillows each night."

A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?

"I'll avoid eating or drinking anything 6 to 8 hours before the test."

A client has sought care because his gums began bleeding when he was flossing his teeth and they have now been bleeding for several hours. Laboratory testing has revealed a platelet count of 60 x 109/l and a diagnosis of thrombocytopenia. Which of the nurse's assessment questions address the possible etiology of this health problem?

"What medications are you currently taking?"

A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response?

"You may have eaten contaminated restaurant food."

A patient was seen in the clinic 3 days previously for allergic rhinitis and was given a prescription for a corticosteroid nasal spray. The patient calls the clinic and tells the nurse that the nasal spray is not working. What is the best response by the nurse?

- "The full benefit of the medication may take up to 2 weeks to be achieved."

A client presents to the health care clinic with reports of swelling, pain, and coolness of the lower extremities. The nurse should recognize that which of these lifestyle practices are risk factors for peripheral vascular disease? Select all that apply.

- Cigarette smoking - Previous use of hormones - High-fat diet

The nurse is preparing the client for a bone marrow aspiration at the posterior iliac crest. What would be the best position for the nurse to place the client in for the test?

- On the side opposite the aspiration site

The nurse is caring for a client who is undergoing bone marrow aspiration to determine the blood cell formation status. What nursing intervention should the nurse provide to the client during the test?

- Support the client and monitor the status.

Peritonitis is an inflammatory condition of the lining of the abdominal cavity. What is one of the most important signs of peritonitis?

- The translocation of intracellular fluid into the peritoneal cavity

The nurse would expect to observe which of the following when assessing a client with cholelithiasis?

- Urine that appears dark brown

A nurse is teaching a client with gastritis about the need to avoid the intake of caffeinated beverages. The client asks why this is so important. Which of the following explanations from the nurse would be most accurate?

-"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."

A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse?

-"Exercise, keep your cholesterol in check, and manage your stress."

A patient recently diagnosed with rheumatoid arthritis (RA) tells the nurse she is glad there is nothing "really wrong with her" but some joint swelling. Which of the following information should the nurse tell the patient about RA?

-"Extra-articular manifestations may include anemia and deformities of the affected joints."

A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching?

-"I should increase my intake of fresh fruits and vegetables during remissions."

A 64 year-old man was diagnosed 19 months ago with bilateral osteoarthritis (OA) in his knees, and has come to his family physician for a checkup. The client and his physician are discussing the affects of his health problem and the measures that the man has taken to accommodate and treat his OA in his daily routines. Which of the following statements by the client would necessitate further teaching?

-"I've been avoiding painkillers because I know they can mask damage that I might be inflicting on my knees."

A client with lymphedema is struggling with negative emotions related to her appearance. Which of the following suggestions from the nurse would be most effective in helping the client address the problem?

-"Let's discuss some clothing styles that can help conceal the problem while you are being treated."

A male patient's present signs and symptoms are suggestive of an incompetent cardiac sphincter, and he has been scheduled for an upper GI series (barium swallow). What preprocedure teaching should the nurse provide to this patient?

-"Make sure that you don't eat anything after midnight the day before your test."

The nurse determines further teaching is necessary when a client diagnosed with osteoarthritis states:

-"Men are more likely to have osteoarthritis than women."

The nurse is caring for a patient diagnosed with osteoarthritis (OA). Which of the following does the nurse teach the patient about the disease?

-"OA is a disease of the weight-bearing joints."

A client with a diagnosis of hemolytic anemia has gone to a community-based laboratory for follow-up blood work. The lab technician confirms with the client that hematocrit is one of the components of the blood work. The client replies, "I thought the point of the blood work was to see how many red blood cells I have today." How could the technician best respond to the client's statement?

-"The hematocrit measures the mass that your red blood cells account for in a quantity of your blood."

A nursing student is caring for one of the nurse's assigned cardiac clients. The student asks, "How can I tell the difference between sinus rhythm and sinus bradycardia when I look at the EKG strip" The best reply by the nurse is which of the following?

-"The only difference is the rate, which will be below 60 bpm in sinus bradycardia." (p. 468)

A patient has been diagnosed with anemia. The physician suspects an immune hemolytic anemia and orders a Coombs test. The patient asks the nurse what this test will tell the doctor. The nurse replies:

-"They are looking for the presence of antibody or complement on the surface to the RBC."

When planning care for the client with severe osteoarthritis (OA) of the hip, the nurse includes which of the following in a teaching session with the patient?

-"Try to balance your rest and exercise." "Using heat or cold to relieve pain may be helpful." "Losing weight or maintaining your ideal weight reduces stress on your joints." "A walker may be helpful to avoid excess pressure on your hips."

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor?

-"You must have the second one in 1 month and the third in 6 months."

A patient is in the hospital for the treatment of peptic ulcer disease. The nurse finds the patient vomiting and complaining of a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect these symptoms indicate?

--Perforation of the peptic ulcer

A client with suspected acute myocardial infarction is admitted to the coronary care unit. To help confirm the diagnosis, the physician orders serial enzyme tests. Increased serum levels of the isoenzyme creatinine kinase of myocardial muscle (CK-MB), found only in cardiac muscle, can be detected how soon after the onset of chest pain?

-4 to 6 hours

The nurse is caring for four clients. Select the client at risk for the development of a pulmonary embolism.

-A 62-year-old male postop repair of a fractured femur

The nurse is assigned to care for four clients on a medical floor. Which client is most at risk for viral pneumonia after influenza?

-A 76-year-old client with cardiopulmonary disease

The health care provider has determined that a client has developed rheumatoid arthritis. The provider is aware that the client may experience joint inflammation that involves of immunologic mediation triggered by:

-A T-cell mediated response to an immunologic trigger, such as a microbial agent

A patient diagnosed with colon cancer presents with the characteristic symptoms of a left-sided lesion. Which of the following symptoms are indicative of this disorder? Select all that apply.

-Abdominal distention Constipation Narrowing stools

Common clinical manifestations of Crohn's disease include:

-Abdominal pain and diarrhea

Which symptom is often observed in cases of peritonitis?

-Abdominal rigidity

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

-Actual

A client reports to the clinic, stating that she rapidly developed headache, abdominal pain, nausea, hiccuping, and fatigue about 2 hours ago. For dinner, she ate buffalo chicken wings and beer. Which of the following medical conditions is most consistent with the client's presenting problems?

-Acute gastritis

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

-Acute pain related to biliary spasms

The nurse advises a client with mitral valve prolapse to avoid the use of alcohol. What is the primary reason for this restriction?

-Alcohol can suppress antidiuretic hormone (ADH), leading to loss of extracellular fluid.

What is a long-term complication of peripheral vascular disease?

-Amputation

A patient's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather that ulcerative colitis, as the cause of the patient's signs and symptoms?

-An absence of blood in the stool

A nurse injecting a client who has HIV/AIDS accidentally sticks herself with the needle. What is the protocol when this type of incident occurs?

-An incident report must be filed immediately

After receiving chemotherapy for lung cancer, a client's platelet count falls to 20 x109L. What term should the nurse use to describe this low platelet count?

-Anemia

The following are symptoms associated with aortic stenosis (AS):

-Angina, syncope, and dyspnea

The nurse is assessing a patient and feels a pulse with quick, sharp strokes that suddenly collapse. The nurse knows that this type of pulse is diagnostic for which disorder?

-Aortic regurgitation

A 13-year-old boy has been brought to the emergency department by his mother after he took a powerful blow to his nose during a volleyball game. Preliminary examination suggests a nasal fracture, which should prompt the nurse to:

-Apply ice and tell the patient to keep his head elevated

A 50-year-old woman was recently diagnosed with non-Hodgkin's lymphoma (NHL) and has begun a treatment regimen that includes simultaneous radiation therapy and chemotherapy. The combination of severe symptoms and aggressive therapy has necessitated admission to the hospital. When providing care for this patient, which of the following actions should the nurse implement?

-Applying standard precautions conscientiously to reduce the patient's risk of infection

A patient complains about chest pain and heavy breathing when exercising or when stressed. Which of the following is a priority nursing intervention for the patient diagnosed with coronary artery disease?

-Assess chest pain and administer prescribed drugs and oxygen

You are caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD?

-Assess the characteristics of chest pain.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

-Assess the client's level of pain and administer prescribed analgesics.

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client?

-Assisting the client to turn, cough, and deep breathe every 2 hours.

Which medication is the drug of choice for sinus bradycardia?

-Atropine (p. 469)

The nurse is providing patient education in anticipation of the patient's scheduled bone marrow aspiration and biopsy. When teaching the patient about care after the procedure, the nurse should encourage the patient to do which of the following?

-Avoid bathing until the site heals.

The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease?

-Avoid eating or drinking 2 hours before bedtime.

When providing discharge instructions for a 50-year-old male client with mitral valve prolapse who does not have hypertension, the nurse should plan to include which instructions?

-Avoid over-the-counter decongestants.

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

-B) Measure abdominal girth according to a set routine.

A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?

-Bibasilar crackles

When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. The nurse documents this finding as which of the following?

-Caput medusae

The nurse is talking with a group of clients who are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

-Change in bowel habits

A nurse discusses risk factors of cholelithiasis with a client. Which risk factors will the nurse include in the teaching? Select all that apply.

-Changes in weight, Cystic fibrosis, Diabetes, Obesity

A very ill client with acute cholecystitis is scheduled for surgery. The surgeon plans to create an incision in the common bile duct to remove stones. The nurse correctly documents this surgery in the electronic medical record using which term?

-Choledochostomy

A client with calculi in the gallbladder is said to have

-Cholelithiasis

A client has been diagnosed with Laennec's cirrhosis. What does the nurse understand that this type of cirrhosis is caused by?

-Chronic alcohol intake

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report?

-Clay colored stool.

A community health nurse is participating in a healthy-living workshop that has been sponsored by a local seniors' center. The discussion has turned to the problem of heart failure, and the nurse is emphasizing preventative measures. When teaching older adults to decrease their future risks of developing heart failure, the nurse should emphasize what action?

-Close blood pressure monitoring and vigilant adherence to hypertension therapy

A patient asks what type of testing is performed to assess for diverticulosis. As the nurse, you know that which of the following is NOT used to assess for diverticulosis?

-Colonoscopy

A client is being seen in the gastroenterology office where you practice nursing. He presents with an infection in the area between the internal and external sphincters. In which of the following chronic diseases is this condition commonly seen?

-Crohn's Disease

A client has been prescribed a beta blocker. The nurse knows that beta blockers can have which effect on the heart?

-Decrease the heart rate

The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise:

-Decreases venous congestion.

Which of the following would be an indication for a transesophageal echocardiography (TEE)?

-Determination of atrial thrombi

A client with mitral stenosis comes to the physician's office for a routine checkup. When listening to the client's heart, the nurse expects to hear which type of murmur?

-Diastolic, rumbling, low-pitched

Patient with myocarditis are sensitive to which of the following medications?

-Digitalis

The nurse is caring for a client following cardiac valve replacement. Which nursing action is correct when obtaining a Homan's sign to screen for thrombophlebitis?

-Dorsiflexion of the foot noting calf pain

The nursing student approaches his instructor to discuss the plan of care for his client diagnosed with peptic ulcer disease. The student asks what is the most common site for peptic ulcer formation? The instructor would state which one of the following?

-Duodenum

Which of the following is a symptom diagnostic of emphysema?

-Dyspnea

The nurse is conducting a staff in-service program on non-Hodgkin's lymphomas. The nurse should include that essentially all people with Burkitt lymphoma have evidence of infection with which of the following?

-EBV

The diagnosis of aortic regurgitation (AR) is confirmed by which of the following?

-Echocardiography

When teaching a community education class on osteoarthritis (OA), the nurse should include which of the following in discussing which individuals are at risk for this problem? Select all that apply.

-Elderly individuals Older women Obese people

The mode of transmission of hepatitis A virus (HAV) includes which of the following?

-Fecal-oral

Which of the following is a nonmodifiable risk factor for coronary artery disease (CAD)?

-Gender

The nurse is caring for a client with suspected right-sided heart failure. What would the nurse know that clients with suspected right-sided heart failure may experience?

-Gradual unexplained weight gain

The nurse is evaluating the effectiveness of drug therapy in a client with hyperlipidemia. Effective therapy is best demonstrated by which laboratory values?

-HDL 58 LDL 96 Cholesterol 178

A nursing student is caring for a client with end-stage cardiomyopathy. The client's spouse asks the student to clarify one of the last treatment options available that the physician mentioned. After checking with the primary nurse, the student would most likely discuss which of the following?

-Heart transplantation

Which of the following therapies are for patient who have advanced heart failure (HF) after all other therapies have failed?

-Heart transplantation

A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for?

-Hemorrhage

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include?

-Hepatitis C increases a person's risk for liver cancer.

A client with Hodgkin's disease is hospitalized and experiencing respiratory distress. In which position should the nurse place the client?

-High Fowler's

The client with a suspected diagnosis of osteoarthritis asks the health care provider how the diagnosis will be confirmed. The best response would be:

-History and physical examination, x-ray studies, and laboratory findings that exclude other diseases

A client is recovering from infectious mononucleosis. For which of the following conditions is the nurse aware that the client may also be at increased future risk?

-Hodgkin's lymphoma

A lymph node biopsy pathology report notes the presence of Reed-Sternberg cells on a patient suspected of having a lymphoma. The nurse interprets the report as indicating which of the following?

-Hodgkin's lymphoma

Riley Thomas, a 23-year-old graduate student, presents at the primary care group where you practice nursing with painless enlargement of the cervical and axillary lymph nodes. He has lost 20 pounds in the last two months and reports an alarming lack of energy. His history is positive for infectious mononucleosis when he was a young teen. From what might Riley be suffering?

-Hodgkin's lymphoma

Which of the following is a modifiable risk factor for coronary artery disease (CAD)?

-Hyperlipidemia

On assessment immediately following cardiac surgery, which of the following conditions would you expect to find in an infant?

-Hypothermia

A nurse is caring for a client with a new prescription of digoxin. Which client statement would require further teaching about digoxin? Select all that apply.

-I will take digoxin with my antacids at night. If I forget a dose, I will catch-up by doubling the next dose I understand that I will need annual blood work to check therapeutic levels

When the nurse notes that, after cardiac surgery, the client demonstrates low urine output (less than 25 mL/h) with high specific gravity (greater than 1.025), the nurse suspects which condition?

-Inadequate fluid volume

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

-Ineffective Airway Clearance

A patient presents to the walk-in clinic complaining of vomiting and burning in her mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the physician is likely to order a diagnostic test to detect the presence of what?

-Infection with Helicobacter pylori

In preparation for transesophageal echocardiography (TEE), the nurse must:

-Inform the patient that blood pressure (BP) and electrocardiogram (ECG) monitoring will occur throughout the test

A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?

-Insertion of a nasogastric tube

The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first?

-Inspect the left lower leg for areas of redness.

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?

-Instruct the client to cough forcefully

A client who has occasional gastric symptoms is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching?

-Irritating foods such as spices, caffeine, and alcohol should be avoided because these will assist in decreasing gastric acidity. Eating smaller meals is recommended to avoid lower pressure in the lower esophageal sphincter. Gastric reflux of acid is more likely to occur with positioning flat and lying down after a meal, so this should be avoided.

Which of the following assessment findings will help the nurse to confirm the diagnosis of rheumatoid arthritis? Select all that apply.

-Joint stiffness Finger and hand pain Wrist pain Limited joint mobility

A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform?

-Keep patient NPO until the patient's gag reflex returns.

The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in?

-Lateral position with one leg flexed

For patients diagnosed with aortic stenosis, digoxin would be ordered for which of the following clinical manifestations?

-Left ventricular dysfunction

Due to her progressing osteoarthritis (OA), an 80 year-old woman is no longer able to perform her activities of daily living without assistance. Which of the following phenomena most likely underlies the woman's situation?

-Loss of articular cartilage and synovitis has resulted from inflammation caused when joint cartilage attempted to repair itself.

A nurse is helping to prepare a client with lymphedema for a procedure in which an intravenous dye and radiography will be used to detect lymph node involvement and reveal the degree and extent of blockage in the lymph system. What procedure will the client be undergoing?

-Lymphangiography

The nurse is conducting patient education for a client who is scheduled to undergo diagnostic testing for non-Hodgkin's lymphoma (NHL). The nurse includes information on which of the following?

-Lymphnode biopsy

What should the nurse teach the patient with diverticulosis to do?

-Maintain a high-fiber diet and use bulk laxatives to increase fecal volume.

Which of the following nursing interventions should a nurse perform to reduce cardiac workload in a patient diagnosed with myocarditis?

-Maintain on bedrest

Ralph Wilson, is a 52-year-old client in the hospital unit where you practice nursing. He is being treated for myocarditis. Which of the following nursing interventions should you perform to reduce cardiac workload in a client with myocarditis?

-Maintain the client on bed rest

A patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes?

-Maintaining fluid and electrolyte balance

For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which acid-base imbalance?

-Metabolic alkalosis

An 82-year-old man is admitted with an acute attack of diverticulitis. What should the nurse include in his care?

-Monitor for signs of peritonitis.

A client with a diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in their arms and legs. What do these symptoms indicate?

-Neurologic involvement

A client has been diagnosed with lymphoma and asks the oncologist for more information about the diagnosis. Which specifics would be included in a diagnosis of non-Hodgkin's lymphoma?

-No Reed-Sternberg cells; B- and T-cell origin; common in abdomen and tonsils; can develop in areas other than lymph nodes

Peptic ulcer disease occurs more frequently in people with which blood type?

-O

Which of the following groups of patients are at risk for thrombophlebitis?

-Older adults

The nurse is caring for a client with aortic regurgitation. The nurse knows to expect which of the following symptoms on physical examination?

-Orthopnea and dyspnea

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?

-Pallor, tachycardia, and a sore tongue

A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. During the 2-hour care ride, what should the nurse should advise the client to do?

-Perform ankle pumps and foot range-of-motion exercises.

The client teaching instructions for a 57-year-old male client with thrombophlebitis who is being discharged should include which of the following? Select all that apply

-Perform leg exercises each hour. Ambulate as tolerated. Avoid sitting for too long.

Which of the following is a late clinical manifestation of mitral stenosis?

-Peripheral edema

A client has developed a ruptured appendix. The nurse is aware the client is at high risk for:

-Peritonitis

A patient is admitted with an abrupt onset of referred pain to the epigastric area, with an episode of nausea. On the nurse's initial assessment, the patient is lying still and taking shallow breaths, with a rigid abdomen. Which of the following problems is the patient experiencing?

-Peritonitis

Which of these measures would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client?

-Placing graduated compression stockings on the client.

A 40-year-old woman is diagnosed with an internal abdominal hernia in which a loop of small bowel has passed through the epiploic foramen and become lodged in the lesser sac. During the procedure to release the hernia, the surgeon finds it necessary to incise the free edge of the lesser omentum. Which of the following structures must the surgeon take care to spare when cutting the lesser omentum?

-Portal vein

A 77-year-old client has newly diagnosed stage 2 hypertension. The physician has prescribed a thiazide and an angio-converting enzyme inhibitor. About what is the nurse most concerned?

-Postural hypotension and resulting injury

A patient's large bowel obstruction has failed to resolve spontaneously and the patient's worsening condition has warranted admission to the medical unit. Which of the following aspects of nursing care is most appropriate for this patient?

-Preparing the patient for surgical bowel resection

The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a patient?

-Prior to surgery

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?

-Protamine sulfate

The nurse is reviewing the chart of a client with lymphoma. Which of the following findings would best indicate to the nurse that the client has Hodgkin's disease as opposed to non-Hodgkin's lymphoma?

-Reed-Sternberg cells are found diagnostically.

The nurse advises the patient who has just been diagnosed with acute gastritis to:

-Refrain from food until the GI symptoms subside.

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

-Respiratory rate of 22 breaths/minute

A client hospitalized with Hodgkin's disease is currently under visitor restrictions and asks the nurse why this is necessary. Which of the following explanations from the nurse is most accurate?

-Restricting visitors and personnel reduces the risk of transmission of pathogens to the client.

What is the most common cause of mitral stenosis?

-Rheumatic endocarditis

After undergoing a liver biopsy, a client should be placed in which position?

-Right lateral decubitus position

Of the following types of hemolytic anemia, which is categorized as inherited disorder?

-Sickle cell anemia

Most patients with diverticulosis are most likely to have diverticula located in the?

-Sigmoid Colon

A patient comes to the emergency department with complaints of chest pain after using cocaine. The nurse assesses the patient and obtains vital signs with results as follows: blood pressure 140/92, heart rate 128, respiratory rate 26, and an oxygen saturation of 98%. What rhythm on the monitor does the nurse anticipate viewing?

-Sinus tachycardia

During his annual physical exam, a 62-year-old male client reports experiencing chest pain and palpitations during and after his morning jogs. Family history reveals coronary artery disease. The nurse should instruct the client in the following to reduce the client's cardiac risk?

-Smoking cessation

A client at the health care facility is diagnosed with Hodgkin's disease that has extended to the liver. What stage should the nurse use to describe the progress of the disease?

-Stage IV

A client was transferring a load of fire wood from his front driveway to his backyard woodpile at 10 a.m. when he experienced a heaviness in his chest and dyspnea. He stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., his wife took him to the emergency department. Around 2 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which orders by the physician?

-Sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry

A visiting nurse is teaching a client with heart failure about taking his medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene?

-Teach a family member to fill a medication compliance aid once per week so the client can independently take his medications.

The nurse is admitting a 45-year-old man to the medical-surgical unit. The patient has a diagnosis of Buerger's disease. While the nurse is taking the patient's health history, he reveals that he smokes about 2 packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority teaching for this patient?

-That cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate Buerger's disease

When the nurse is obtaining a health history from an older adult, which information in the history is a risk factor associated with deep vein thrombosis (DVT)?

-The client recently had abdominal surgery.

A client will be having a bone marrow aspiration to determine the status of blood cell formation. What role does the nurse have during the test?

-The nurse assists the physician and supports the client during the procedure.

A nurse is caring for a child that just had open-heart surgery and the parents are asking why there are wires coming out of the chest of the infant. What is the best response by the nurse?

-These wires are connected to the heart and will detect if your child's heart gets out of rhythm.

In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD?

-To decrease workload of the heart

Wilkins Booth, a 70-year-old male, is a client in the long-term care facility where you practice nursing. Mr. Booth has a history of lymphedema. What is an important part of your assessment as a result of impaired nutrition to his tissues?

-Ulcers and infection in the edematous area

A client presents to his physician with a red face, hands, feet, and ears; a headache; and drowsiness. A blood smear reveals an increased number of erythrocytes. Based on the laboratory results, the nurse prepares teaching material for which disease process?

-Unregulated overproduction of the red cell mass is termed polycythemia.

3. A patient with a history of diverticulosis is admitted with abdominal pain. The physician suspects diverticulitis. What other findings would correlate with diverticulitis?

-Unrelenting cramping type -Blood in stool - Fever - Reports of constipation - Abdominal bloating

A patient with a history of diverticulosis is admitted with abdominal pain. The physician suspects diverticulitis. What other findings would correlate with diverticulitis?

-Unrelenting cramping type pain - Blood in stool - Fever - Reports of constipation - Abdominal bloating

A client comes to the emergency department complaining of visual changes and a severe headache. The nurse measures the client's blood pressure at 210/120 mm Hg. However, the client denies having hypertension or any other disorder. After diagnosing malignant hypertension (hypertensive emergency), a life-threatening disorder, the physician initiates emergency intervention. What is the most common cause of malignant hypertension (hypertensive emergency)?

-Untreated hypertension

The school nurse is educating students regarding the practice of safe sex to avoid contracting HIV. Which of the following would the nurse recommend to provide safer sex?

-Using condoms

Which of the following is the most effective strategy to prevent hepatitis B infection?

-Vaccine

A client is admitted to the hospital with an exacerbation of his chronic gastritis. When assessing his nutritional status, the nurse should expect a deficiency in:

-Vitamin B-12

A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patient's stools will have what characteristics?

-Watery with blood and mucus

The client shouldn't eat or drink for 6 to 12 hours before the procedure to assure that his upper GI tract is clear for viewing. The client will receive a sedative before the endoscope is inserted that will help him relax, but allow him to remain conscious.

-While preparing a client for an upper GI endoscopy

The nurse is assigned to care for a patient 2 days after an appendectomy due to a ruptured appendix with resultant peritonitis. The nurse has just assisted the patient with ambulation to the bedside commode when the patient points to the surgical site and informs the nurse that "something gave way." What does the nurse suspect may have occurred?

-Wound dehiscence has occurred.

You feel a hernia in a male patient and you use your finger to push the hernia contents back into the abdomen through the inguinal canal. In performing this procedure, which of the following is not correct?

-Your finger compressed the inferior epigastric artery within the canal

Which statement describes emphysema?

-a disease of the airways characterized by destruction of the walls of overdistended alveoli

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of:

-acute pulmonary edema.

A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden onset of shortness of breath and chest pain that increases with a deep breath. The nurse should first:

-assess the oxygen saturation.

The nurse is teaching a client with heart failure how to avoid complications and future hospitalizations. The nurse is confident that the client has understood the teaching when the client identifies which potential complications? Select all that apply.

-becoming increasingly short of breath at rest weight gain of 2 lb (0.9 kg) or more in 1 day having to sleep sitting up in a reclining chair

Is 63-year-old patient has buergers disease. What is the most important aspect of patient's compliance to decrease signs and symptoms of burgers disease?

-cessation of Tobacco use

A patient is suspected to have diverticulosis without symptoms of diverticulitis. What diagnostic test does the nurse anticipate educating the patient about prior to scheduling?

-colonoscopy

Following a total joint replacement, which complication has the greatest likelihood of occurring?

-deep vein thrombosis

The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4° F (38° C). The nurse should assess the client further for signs of:

-deep vein thrombosis (DVT) in the left leg.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:

-forcing blood into the deep venous system.

The nurse is conducting a community education program on peptic ulcer disease prevention. The nurse includes that the most common cause of peptic ulcers is:

-gram-negative bacteria.

A client who has Hodgkin's disease should have their bed in high-Fowler's position whenever practical to:

-increase lung expansion.

A client with osteoarthritis states that every morning "it gets harder and harder to loosen up". The client's main therapy to this point is the use of over-the-counter nonsteroidal anti-inflammatories (NSAIDs). These drugs reduce the client's pain by:

-inhibiting prostaglandin synthesis.

A nurse is assessing a client with aortic stenosis. The nurse expects to hear a murmur that is:

-loud and rough during systole.

The nurse analyzes a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm as

-normal sinus rhythm.

When a nurse is assessing a patient with osteoarthritis, which of the following factors poses a risk factor for the disease?

-obesity

A nurse is caring for a client who is undergoing a diagnostic workup for a suspected GI problem. The client reports gnawing epigastric pain following meals and heartburn. The nurse suspects the client has:

-peptic ulcer disease.

A client is scheduled to undergo a bone marrow aspiration and biopsy. The nurse understands that which site would most likely be used?

-posterior iliac crest

Prophylactic heparin therapy is prescribed to treat thrombophlebitis in a multiparous client who gave birth 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when she states which as the purpose of the drug

-prevent further blood clot formation

A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What type of dysrhythmia would the cardiologist likely diagnose?

-sinus tachycardia

A 20-year-old client visiting the clinic requests the use of oral contraceptives. When reviewing the client's history, which finding would alert the nurse to a possible contraindication to using these agents?

-thrombophlebitis

A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest

-thrombophlebitis

The nurse interviews a 22-year-old female client who is scheduled for abdominal surgery the following week. The client is obese and uses estrogen-based oral contraceptives. This client is at high risk for development of

-thrombophlebitis

A client has a history of lymphedema. Impaired nutrition to the client's tissues could lead to:

-ulcers and infection in the edematous area.

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client?

-venous insufficiency

During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing

-venous insufficiency.

An older adult client has recently been diagnosed with rheumatoid arthritis. The nurse should recognize the need to monitor the client's:

-weight and nutritional status.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

-yellow sclerae.

When a nurse is assessing a patient with osteoarthritis, which of the following does the nurse note are consistent with this disorder? Select all that apply.

-• Aching diffuse pain in the involved area • Grating sensation palpated upon movement • Presence of Heberden nodes

A 30-year-old asymptomatic female client has tested positive for the presence of human immunodeficiency virus (HIV) infection. She is apprehensive that she may transmit the disease to other family members. What is true regarding the transmission of HIV? Select all that apply.

-•Transmitted through unprotected sex • Transmitted through blood transfusion • Transmitted through breast milk

A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis?

A liver biopsy

Decreased production of granulocytes

Agranulocytosis:

The nurse is auscultating the heart of a patient diagnosed with mitral valve prolapse. Which of the following is often the first and only manifestation of mitral valve prolapse?

An extra heart sound

A deficiency of either erythrocytes or hemoglobin

Anemia:

The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?

Arterial blood gas (ABG) findings

Results from administration of a killed or weakened microorganism or toxoid: Example: Influenza vaccine

Artificially acquired active immunity:

Which condition most commonly results in coronary artery disease (CAD)?

Atherosclerosis

A nurse is providing education about hypertension to a community group. One client reports that his doctor has diagnosed him with hypertension, but that he feels just fine. He asks, "What would happen if I did not treat my hypertension?" Which of the following are possible consequences of untreated hypertension? Choose all that apply.

Coronary artery disease Myocardial infarction Stroke

The nurse anticipates that the initial treatment for small bowel obstruction will involve which of the following?

Decompression of bowel via nasogastric tube

A 57-year-old man is diagnosed with thrombocytopenia. The nurse knows that thrombocytopenia refers to a decrease in the number of circulating platelets. The nurse also knows that thrombocytopenia can result from what?

Decreased platelet production

A nurse is caring for a client receiving heparin therapy who has developed heparin-induced thrombocytopenia. Which of the nursing interventions does the nurse anticipate?

Discontinuation of heparin therapy

A rheumatology nurse is teaching a patient about extra-articular signs and symptoms of rheumatoid arthritis (RA). Which of the following does the nurse include in the teaching session? Select all that apply.

Fatigue • Loss of appetite • Aching • Stiffness

A patient has been diagnosed with rheumatoid arthritis (RA). Which of the following will the nurse tell the patient about this disorder's etiology?

Genetic predisposition is very likely."

A pneumonia that occurs 48 hours or more after admission to the hospital is considered:

Hospital-acquired pneumonia.

A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply.

Hyperlipidemia -Obesity -Tobacco use

Potassium chloride may be administered in the patient with small bowel obstruction and dehydration to correct hypokalemia. The nurse knows that a patient experiencing decreased potassium levels would exhibit which of the following signs and symptoms?

Hypotension, muscle weakness

The nurse is aware that untreated small bowel obstruction can progress to which type of shock?

Hypovolemic

In the patient experiencing small bowel obstruction, vomiting can result in severe dehydration. Laboratory values that would reflect this include which of the following?

Increased Hematocrit

A client who was admitted to the cardiac intensive care unit with a diagnosis of myocarditis asks the nurse what caused his disease. What would be the nurse's best response?

It is usually caused by a viral infection

What are the criteria categories required for the diagnosis of rheumatoid arthritis (RA)? Select all that apply.

Joint involvement • Serology • Acute phase reactants • Duration of symptoms

Following the removal of a woman's axillary lymph nodes because of breast cancer, she developed lymphedema of the ipsilateral upper limb. Why did this occur?

Lymph drainage from the limb was impeded by the absence of the nodes

Occurs as a direct result of infection by a specific microorganism

Naturally acquired active immunity:

A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock?

Neurogenic

Conditions in which numbers of all marrow-produced blood cells are reduced.

Pancytopenia:

Ready-made antibodies are given to a susceptible person. Example: Newborns receive passive immunity to some diseases.

Passive immunity:

After teaching a group of students about the types of anemia, the instructor determines that the teaching was successful when the students identify which anemia results from an inability to produce the intrinsic factor?

Pernicious anemia

You are a student nurse being precepted in the ICU. You are caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the reabsorption and retention of fluid in the body?

Production of antidiuretic hormones and corticosteroid hormones.

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?

Reduce fluid accumulation and venous pressure

You are caring for a client in the compensation stage of shock. You know that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do?

Restores blood pressure

A nurse is monitoring a client with peptic ulcer disease. Which of the following assessment findings would most likely indicate perforation of the ulcer? Choose all that apply.

Tachycardia Hypotension A rigid, board-like abdomen

A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care?

The client will be monitored closely to detect malignant changes.

The nurse is caring for a client with multiple organ failure who is in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid.

A client arrives in the clinic with a cough, fever, and chest discomfort and is diagnosed with community-acquired pneumonia. What education does the nurse anticipate providing prior to discharging the client from the clinic?

The use of antibiotics

A nurse is treating a client with aplastic anemia. Due to the replacement of normal bone marrow with malignant cells, the nurse teaches the client to prevent scratches, scrapes, and cuts. What root cause likely underlies the client's increased risk for hemorrhage?

Thrombocytopenia

During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes a painful ulcer at the ankle. The nurse suspects the client may have what?

Venous insufficiency

For a patient diagnosed with pernicious anemia, the nurse emphasizes the importance of lifelong administration of which of the following?

Vitamin B12

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory results does the nurse note as a key in determining the type of shock?

WBC: 42,000 -Septic shock

Which of the following is the most significant risk factor for mitral stenosis?

Which of the following is a late clinical manifestation of mitral stenosis?

The nurse is aware that the most common cause of small bowel obstruction is which of the following?

adhesions

which ofthe following are assessment findings by the nurse that suggest a resolving bowel obstruction?

decreased ng tube output and passage of flatus

A client is being treated for diverticulosis. Which information should the nurse include in this client's teaching plan?

in this client's teaching plan? -Drink at least 8 to 10 large glasses of fluid every day

A 40 year-old man who uses heroin intravenously was diagnosed with hepatitis C (HCV) one year ago and now has chronic viral hepatitis. Which of the following statements by the client to his care provider would warrant correction by the nurse?

it is at least a bit reassuring that my liver isn't undergoing damage when I'm not -experiencing symptoms.

common symptoms during a myocardial infarction

severe chest pain, shooting pain down the left arm, severe dizziness and nausea, tightening of neck or jaw muscles, shortness of breath or trouble breathing, fear/feeling of impending doom, excessive sweating

A client is diagnosed with a dysrhythmia at a rate slower than 60 beats/minute. What type of dysrhythmia does the client have?

sinus bradycardia

In order to prevent deep vein thrombosis (DVT) following abdominal surgery, the nurse should:

use pneumatic compression stockings.

The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes

vasospasm.

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks an update on the client's condition. A family member asks, "What causes the body to go into shock?" Given the client's condition, which statement is most correct?

- "The client is in shock because the blood volume has decreased in the system." (Hypovolemic)

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?

- Administer the prescribed normal saline bolus and insulin.-metabolic acidosis

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?

- Assign the patient to a room near the nurse's stations.

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make?

- Daily alcohol intake (Hypomagnesemia is associated with alcoholism.)

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?

- Encourage fluid intake up to 4000 mL every day. (to decrease the risk for renal calculi)

A patient who had a transverse colectomy for diverticulosis 18 hour ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

- Give the patient PRN IV morphine sulfate 4 mg

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?

- Gradually decreasing level of consciousness (LOC)

Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia?

- Hypomagnesemia. nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia.

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct?

- Hypovolemic shock; blood loss, cardiogenic shock; myocardial infarction, anaphylactic shock; nuts, septic shock; infection

An older adult patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result would the nurse report to the health care provider immediately?

- Na+ of 154 mEq/L

A 64-year-old client is brought into the clinic feeling thirsty with dry, sticky, mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client?

- No, the sodium intake should be restricted

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?

- Notify the patient's health care provider. (The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia)

After receiving a 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 is reviewing the client lab work for a critical lab value. Which value is called to the physician for additional orders?

- Potassium: 5.8 mEq/L

You are caring for a client with severe hypokalemia. The physician has ordered IV potassium to be administered at 10 mEq/hr. The client complains of burning along his vein. What should you do?

- Seek a physician's order to dilute the infusion

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

- The patellar and triceps reflexes are absent (the loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels.)

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

- The patient is experiencing laryngeal stridor (Hypocalcemia can cause laryngeal stridor)

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?

- a feeling of swelling at the back of the throat

A clinic nurse has been charged with the responsibility of teaching avoidance strategies to an adult patient who has allergic rhinitis. What measure should the nurse recommend to this patient?

-"If possible, make sure that no one smokes tobacco in your home."

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?

-10 to 15 seconds

A client has developed community-acquired pneumonia and is being treated at home. What does the nurse recognize are the methods in the diagnosis of community-acquired pneumonia? Select all that apply.

-Age -Coexisting health problems -Severity of illness

A client's arterial blood gas analysis reveals an excess of carbon dioxide. The nurse should recognize that this is consistent with which of the following?

-An increased level of dissolved carbon dioxide (PaCO2) indicates respiratory acidosis.

The infection control nurse at a large hospital has instituted a new education campaign aimed at reducing the incidence of hospital-acquired pneumonia (HAP). The nurse should identify which client as being particularly susceptible to hospital-acquired pneumonia?

-An intubated client who is ventilator dependent following a traumatic head injury

A client is receiving chemotherapy for the diagnosis of brain cancer. When teaching the client about contamination from excretion of the chemotherapy drugs within 48 hours, what should the nurse tell the client?

-Any contaminated linens should be washed separately and then washed a second time, if necessary.

The nurse should advise the patient who has nasal packing for epistaxis that the packing can be left in place:

-Anywhere from 2 to 6 days.

A client comes into the emergency department with epistaxis. What intervention should you perform when caring for a client with epistaxis?

-Apply direct continuous pressure.

Which of the following is a potential complication of a low pressure in the endotracheal tube (ET) cuff?

-Aspiration pneumonia

A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time?

-Assess for a cough reflex.

For a client with an endotracheal (ET) tube, which nursing action is the most important?

-Auscultating the lungs for bilateral breath sounds

When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?

-Bronchitis

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level?

-Cardiac dysrhythmias

A patient is diagnosed with pulmonary embolism. Which of the following symptoms would most likely be present?

-Chest pain and dyspnea

Which assessment finding puts a client at increased risk for epistaxis?

-Cocaine use

The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated?

-Deflating the cuff routinely

The experienced nurse is teaching a new nurse about chemotherapy administration. What teaching will the experienced nurse include?

-Double-glove when administering these drugs. -Pharmacists must be specifically trained to prepare chemotherapy agents. -Central venous catheters (CVC) are often used to administer antineoplastic drugs.

What nursing action has the greatest potential to prevent pulmonary embolism in patients in the post-op unit

-Early ambulation and use of compression stockings.

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find?

-Hypokalemia

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L Potassium: 3.2 mEq/L Calcium: 4.4 mEq/L Magnesium: 1.6 mEq/L Chloride: 100 mEq/L Phosphate: 1.8 mEq/L Based on these levels, the nurse would identify which imbalance?

-Hypokalemia

A nurse is reading a journal article about medications used to treat allergic rhinitis. The nurse demonstrates understanding of the information when identifying which medication as being the most effective maintenance therapy for chronic allergic rhinitis?

-Intranasal corticosteroids

What disadvantages of chemotherapy should the patient be informed about prior to starting the regimen?

-It targets normal body cells as well as cancer cells.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for

-Kink in the ventilator tubing

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

-Kinking of the ventilator tubing

Elderly people are very susceptible to pneumonia in all its varieties. The symptoms the elderly exhibit can be very different than those of other age groups who have pneumonia. What signs and symptoms are elderly people with pneumonia less likely to experience than people with pneumonia in other age groups?

-Marked elevation in temperature

A pulmonary embolism occurs when there is an obstruction in the pulmonary artery blood flow. Classic signs and symptoms of a pulmonary embolism include dyspnea, chest pain, and increased respiratory rate. What is a classic sign of pulmonary infarction?

-Pleuritic pain

A 40-year-old male presents to the emergency department reporting chest pain and shortness of breath. The health care provider suspects a pulmonary embolism and orders several diagnostic tests. Select the test that would require further follow-up.

-Positive D-dimer

You are caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when you will allow the patient to drink fluids?

-Presence of a cough and gag reflex

A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure?

-Pressure necrosis Tracheal bleeding Tracheal aspiration

A client has been diagnosed with deep vein thrombosis (DVT). The nurse is planning care and recognizes that the client is most at risk for:

-Pulmonary embolism

Three days following surgical repair of a hip fracture a client becomes anxious and complains of sudden shortness of breath. What disorder is the client most likely experiencing?

-Pulmonary embolism

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

-Respiratory acidosis

The nurse is caring for a client with chronic obstructive pulmonary disease. The client reports that he is having difficulty breathing and is feeling fatigued. The nurse realizes that this client is at high risk for which condition?

-Respiratory acidosis

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:

-Symmetry of the client's chest expansion

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?

-The patient is hypoxic from suctioning.

A nurse is providing care for an older, previously healthy adult male who has been diagnosed today with pneumococcal pneumonia. Which of the following signs and symptoms is the nurse most likely to encounter?

-The patient will have a cough producing clear sputum, and he will have faint breath sounds and fine crackles.

The nurse evaluates teaching as effective when a female client states that she will

-Use sunscreen when outdoors

A 44-year-old woman has developed calf pain during a transatlantic flight. She is extremely short of breath upon arrival at her destination. She was subsequently diagnosed with a pulmonary embolism (PE) that resolved with anticoagulant therapy. Which statement best characterizes the underlying problem of her PE?

-Ventilation was occurring but perfusion was inadequate, causing shortness of breath.

The nurse is caring for a patient admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been completed. Which of the following interventions should the nurse include in the patient's care?

-apply a ice pack

A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

-cardiac irregularities

The nurse is evaluating the client's risk for cancer and recommends changes when the client states she

-eats red meat such as steaks or hamburgers every day

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:

-hyponatremia

In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis?

-ineffective airway clearance

The nurse should assess a client for which complications associated with disseminated intravascular coagulation (DIC)?

-pulmonary embolism

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:

-sit upright, leaning slightly forward.

A nurse is caring for a client who is undergoing chemotherapy. Current laboratory values are noted on the medical record. Which action would be most appropriate for the nurse to implement?

-washing hands before and after entering the room

A client with seasonal allergic rhinitis comes to the clinic for a check-up. During the visit, the client tells the nurse that the symptoms primarily occur in the early fall. The nurse would suspect that the client has an allergy to which substance?

-weed pollen

You are the nurse caring for a client in septic shock. You know to closely monitor you client. What finding would you observe when the client's condition is in its initial stages?

A rapid, bounding pulse.

You are an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would you be sure to include in your workshop? Select all that apply.

A) Alcohol C) Tobacco D) Industrial pollutants

A client was admitted to your unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and his family? Select all that apply.

A) Drink at least eight glasses of fluid each day. D) Drink water as an inexpensive way to meet fluid needs. E) Respond to thirst.

You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client? -

Adrenergic drugs

You are a nursing student preparing to care for an ICU client with shock. Your instructor asks you to name the different categories of shock. Which of the following is a category of shock?

Distributive (The four main categories of shock are hypovolemic, distributive, obstructive, and cardiogenic

You are caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. You know that you should take extra care to check for signs of bruising or bleeding in what condition?

Hypocalcemia (Hypocalcemia or low serum calcium levels can affect clotting)

A family physician is performing patient teaching about the influenza virus with each patient who has come to the clinic to receive that year's vaccine. Which of the following statements by the patient best reflects an accurate understanding of the flu virus?

I could come down with viral or bacterial pneumonia as a result of a bad flu bug."

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?

In dehydration, only extracellular is depleted.

While completing an admission assessment, the client reports a family history of ovarian cancer among a maternal grandmother, aunt, and sister. The nurse knows that these cancers are most likely associated with what etiology?

Inherited gene mutation

Which nursing action is anticipated by the nurse to restore colloidal osmotic pressure to clients with third-spacing?

Initiate an IV of albumin.

The nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status?

Weight