adult health theory exam 2

A nurse caring for client who has hypernatremia and requires IV fluid therapy due to NPO status. Which of the following solutions should the nurse prepare to infuse for this client? A. Lactated Ringer's B. Dextrose 5% in 0.9% sodium chloride C. 0.45% sodium chloride D. Dextrose 10% in water

0.45% sodium chloride

A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which statement indicates to the nurse that the client understands the instructions?1-I will sleep on my left side2-I will sleep on my right side3-I will sleep on my back with my head flat4-I will sleep on my stomach with my head flat

2

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?a. Troponin Ib. Lipasec. BNPd. AST

A

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?A. Obtain a pair of slipper socks for the clientB. Rub the client's feet briskly for several minutesC. Increase the client's oral fluid intakeD. Place a moist heating pad under the client's feet

A

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?A. Measure the circumference of both upper arms.B. Remove the PICC line.C. Apply a cold pack to the client's upper arm.D. Notify the provider who inserted the PICC line.

A

A nurse is caring for client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess? a. The surgical dressing b. The patency of the NG tube c. The coping ability of the client d. The client's bowel sounds 24-48

A

A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0-10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?a. Admin another nitroglycerin tabletb. Initiate a peripheral IVc. Call the Rapid Response Teamd. Obtain an ECG

A

When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following? A. Arterial insufficiency B. Venous insufficiency C. Within the expected range D. Thrombus formation in the vein

A

a nurse is providing education for a client who has glaucoma. which of the following statements should the nurse include in the teaching? A. "Without treatment, glaucoma can cause blindness" B. "Double vision is a common symptom of glaucoma" C. "Glaucoma is caused by inadequte production of fluid within the eye" D. "Use of eye drops will improve vision over time"

A

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)A. increased heart rateB. increased blood pressureC. increased respiratory rateD. increased hematocritE. increased temperature

A, B, C

A nurse is providing discharge teaching to a client who will be receiving total parenteral nutrition (TPN) at home. Which of the following instructions should the nurse include? (Select all that apply) a. "Keep the TPN refrigerated when not in use"b. "Infuse 10% dextrose and water if the solution runs out"c. "Shake the TPN bag with fat emulsion is precipitate is present"d. "Stop using TPN once weight gain is achieved"e. Maintain TPN infusion rate when behind schedule"

A, B, and E

A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventionsshould the nurse include in the client's plan of care? (Select all that apply.)A. Check peripheral pulses in the affected extremity.B. Place the client in high-Fowler's position.C. Measure the client's vital signs every 4 hr.D. Keep the client's hip and leg extended.E. Have the client remain in bed up to 6 hr

A, D, and E

A nurse is teaching a client strategies to manage gastroesophageal reflux disease (GERD). Which of the following statements should the nurse include? A. "Elevate the head of your bed by 18 inches" B. "Avoid snacking between meals" C. "Limit foods that are high in fiber" D. "Avoid eating 2-3 hours before bedtime"

Avoid eating 2-3 hours before bedtime

A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action?A. Place the client in a supine position postoperatively.B. Encourage ambulation once fully awake.C. Offer the client ice cream postoperatively.D. Instruct the client not to lift over 4.5 kg (10 lb)

B

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?a)Sleep on the abdomen to facilitate wound healing.b)Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.c)Bend at the waist to pick objects up from the floor.d)Notify the surgeon if white drainage develops on the eyelids.

B

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?A. Include foods high in starch and proteins.B. Include foods high in fiber.C. Avoid foods high in fat.D. Avoid foods high in sodium.

C

A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia? A. Dietary iron restrictions B. Intestinal malabsorbtion syndrome C. Chronic blood loss D. Intestinal parasites

C

A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. which of the following foods should the nurse tell him to avoid A. Nonfat milk B. Chocolate C. Apples D. Oatmeal

Chocolate

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to reporta)loss of central vision.b)having a loss of peripheral vision.c)seeing bright flashes of light and floaters.d)having a decreased ability to perceive colors.

D

A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for? A. Elevated sodium level B. Decreased potassium level C. Elevated magnesium level D. Decreased calcium level

Decreased potassium level

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.) Genetic predisposition, Hypercholesterolemia, Hypertension, Obesity, Smoking

Hypercholesterolemia, Hypertension, Obesity, Smoking

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs shouldindicate to the nurse that the client has developed a thrombus? A. Positive Kernig's sign Rationale: Kernig's sign indicates meningeal irritation. B. Positive Homan's sign Rationale: Homan's sign has shown to be unreliable since only a small percentage of clients who have a thrombus exhibit it, and performing it could possibly mobilize the clot. C. Dull, aching calf painRationale: Dull, aching calf pain is a sign of deep-vein thrombosis. Other manifestations are edema,warmth, and redness in the calf. D. Soft, pliable calf muscleRationale: A thrombus is more likely to cause muscle rigidity than a soft and pliable muscle.

Dull, aching, calf pain

A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following? A. Dilated pupils B. Dysrhythmias C. Diarrhea D. Gastric ulcer

Dysrhythmias

A nurse is receiving a client who is immediately postoperative following hip arthroplasty. Which of the following medications should the nurse plant to administer for DVT prophylaxis? A. Aspirin PO B. Enoxaparin subcutaneous C. Heparin infusion D. Warfarin PO

Enoxaparin subcutaneous

A nurse in an emergency department is caring for a client who has abdominal pain. Nurses' Notes 0800: Client reports abdominal pain that began the previous evening. Client is two weeks postoperative from a right knee replacement. Reports taking 3 to 4 hydrocodone tablets daily for postoperative pain. Has not had bowel movement in 4 days. Reports not drinking many fluids to avoid having "to get up and go to the bathroom so often because it hurts to walk." 0830: Client taken for abdominal x-ray. Partner reports that client has not been following physical therapist's exercise regimen of walking several times daily. 0915: Fecal mass of hard, dry stool removed digitally from client per provider's order. 1015: Provided teaching to client and partner about constipation and methods to avoid further impaction. Diagnostic Results 0900:Abdominal x-ray: Large amount of fecal material throughout the colon with rectal impaction. No evidence of small bowel obstruction. A nurse is providing teaching to a client who has constipation. Which of the following information should the nurse include? (Select all that apply.) Increase intake of low fiber foods. Avoid drinking hot liquids. Increase daily exercise

Increase fluid intake to 1500 ml daily, increase probiotic foods in the daily diet, increase daily exercise

A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment? A. Lethargy B. Hyperactive deep tendon reflexes C. Prolonged ST segment D. Hyperactive bowel sounds

Lethargy

A nurse is establishing health promotion goals for a female client who smokes cigarettes. Has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? a. The client will list foods that are high in calcium, which should be avoided b. The client will walk for 30 min/5 days a week c. The client will increase calorie intake by 200 cal per day d. The client will replace cigarettes with smokeless tobacco products

The client will walk for 30min/5 days a week

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take? A. Suggest that the client use a salt substitute B. Obtain a 12-lead ECG C. Advise the client to add citrus juices and bananas to her diet D. Obtain a blood sample for a serum sodium level

Obtain a 12-lead ECG

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate (Kayexalate). If this medication is effective, the nurse should expect which of the following changes on the client's ECG? A. reduction of t-wave amplitude B. Shortening of p-wave duration C. Widening of the QRS complex D. Restoration of QRS complex amplitude

Reduction of T-wave amplitude

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?A. Review the client's electrolyte values.B. Check the client's perianal skin integrity.C. Investigate the client's emotional concerns.D. Obtain a dietary history from the client.

Review the client's electrolyte values

A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make?A. "Take only one dose of nitroglycerin to reduce the risk of getting a headache."B. "There's nothing that can be done to relieve the headaches that nitroglycerin causes."C. "Try taking a mild analgesic to relieve the headache."D. "We will ask the provider to prescribe a different medication for you."

T

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A. Hyperactive reflexes B. Extreme thirst C. Weak, irregular pulse D. Hyperactive bowel sounds

Weak, irregular pulse

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect? A. Fatty stools B. Straw-colored urine C. Tenderness in the left upper abdomen D. Ecchymosis of the extremeties

fatty stools