Adult Medical Surgical Practice A

53. A nurse is providing dietary teaching to a client who is post-operative following a thyroidectomy with removal of the parathyroid glands the nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet

12 almonds because they are the best source of calcium to recommend because they contain 36 milligrams of calcium removal of the parathyroid glands which regulate calcium in the body can result in hypocalcemia

34. A nurse is caring for a client who has a new prescription for tpn the client is to receive 2,000 kcalories per day the t-pn solution has 500 kcalories per liter the IV pump should be set at how many milliliters per hour

167 milliliters per hour

76. A nurse on a medical-surgical unit is receiving change of shift report on four clients which of the following clients should the nurse identify as having the greatest risk for developing an infection

A client who has COPD and is receiving steroid therapy because of decreased oxygenation and increased mucus production additionally taking a steroid medication increases the client's risk for infection by suppressing the immune system and masking the presence of an infection

50. A nurse is caring for a client who is exhibiting manifestations of a febrile reaction while receiving a blood transfusion which of the following medications should the nurse administer

Acetaminophen to reduce fever and decreased the manifestation of the febrile reaction include tachycardia fever hypotension and chills the nurse should discontinue the transfusion and return the blood bag and tubing to the blood bank

21. A nurse is caring for a client who is receiving tpn a new bag is not available when the current infusion is nearly completed which of the following actions should the nurse take

Administer dextrose 10% in water until the new bag arrives. Tpn Solutions have a high concentration of dextrose therefore if a t-pn solution is temporarily unavailable the nurse administer dextrose 10% or 20% and water to avoid a precipitous drop in the client's blood glucose level

16. A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take?

Administer the medication at the same time each day. The nurse administer the medication to the client at the same time each day to maintain consistent serum levels

20. A nurse is in a provider's office is providing teaching to a client who has a urinary tract infection and a new prescription for ciprofloxacin. Which of the following instructions should the nurse include

Avoid taking magnesium containing antacids with this medication. The nurse should instruct the client to take Ciprofloxacin either two hours before or 6 hours after taking an antacid but not to take Ciprofloxacin with an antacid because magnesium containing antacids decrease the absorption of Ciprofloxacin

81. A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit

Heart rate of 110 per minute Urine SG: 1.002-1.030 + dehydration BUN: 7-21 above 60-80 is critical HR: 60-100 BP: 120/80

30. A nurse is caring for a client who has a new diagnosis of hyperthyroidism which of the following is the priority assessment finding that the nurse should report to the provider

Blood pressure of 170 over 80 because using the Urgent vs. Non-urgent approach to client care the nurse determines that the priority funding is a systolic blood pressure of 170 which indicates that the client is at risk for thyroid storm

13. A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching?

I will eat more high-fiber foods. The client should eat high-fiber foods to help prevent constipation which is a common adverse effect of oral iron supplements.

7. A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? Select all that apply.

Calf pain, numbness in the arms and intense headache. Calf pain is an indication of DVT and the client should report this finding to the provider immediately. Numbness in the arms can indicate cerebrovascular accident which is an adverse effect of hormone replacement therapy and an intense headache can indicate a cerebrovascular accident.

55. A nurse is performing a dressing change for a client who is recovering from a hemicolectomy when removing the dressing with the nurse notes that a large part of the bowel is protruding through the abdomen which of the following actions should the nurse take first

Call for help evidence based practice indicates that the nurse should first stay with the client and call for assistance the client will require emergency surgery and is at risk for shock therefore the nurse should attain immediate assistance

2. A nurse is caring for a client who is receiving plasmapheresis through a venous access site. Which of the following actions should the nurse take?

Check electrolyte levels before and after therapy. R: Plasmapheresis can cause citrate induced hypocalcemia. Therefore the nurse should monitor the clients electrolyte levels before and after therapy.

12. A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?

Check for the type and number of units of blood to administer. According to evidence based practice the nurse should first confirm that the type and number of units of blood to administer matches what is indicated in the clients medication administration record.

74. A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall during the assessment the client states last week I crashed my car because my vision suddenly became blurry which of the following actions is the nurses priority

Check the clients neurologic status because the first action you should take is to assess the client

63. A nurse is providing teaching to a female client who has a history of urinary tract infections which of the following information should the nurse include in the teaching

Clean the perineum from front to back after voiding or defecating to avoid introducing bacteria to the urethra

58. A nurse is planning care for a client who is post-operative following a laparotomy and has a closed suction drain which of the following actions should the nurse take to manage the drain

Compress the drain Reservoir after emptying because it creates a vacuum that draws fluid out of the room through the drain and into the reservoir

23. A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect?

Constipation. A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism resulting and slow motility of the gastrointestinal tract. The nurse should instruct the client to increase fiber and fluid and take to reduce the risk of constipation

38. A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish and ureterostomy. Which of the following statements should the nurse include in the teaching

Cut the opening of The Skin Barrier one eighth of an inch wider than the stoma. The client should cut the opening of The Skin Barrier 1/8 inch wider than the stoma to minimize irritation of the skin from exposure to urine

6. A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?

Paco2 of 56. A client who has COPD retains paco2 due to the weakening and the collapse of the alveolar sacs which decreases the area and lungs for gas exchange and causes the paco2 to increase above the expected reference range. PaCO2: HCO3: Ph:

82. A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy which of the following actions should the nurse take

Demonstrate ways to deep breathe and cough to prevent respiratory complications Advanced solid foods with the return of peristalsis about 1-2 days after surgery. Adhesive strips will begin to fall off 7-10 days after application provider will remove it during that time. Ambulation as soon as possible to prevent DVT.

51. A nurse is assessing a client who has hypokalemia which of the following manifestations should the nurse expect

Decreased peristalsis due to a decrease in gastrointestinal smooth muscle contraction Facial Twitching: Manifestation of Hyperkalemia. Bounding Peripheral Pulses: Manifestation of Hypernatremia with Hypervolemia. Hyperreflexia: Manifestation of Hypocalcemia, Hypomagnesaemia, and Hyperphosphatemia.

18. A nurse in an emergency department is admitting a client who reports dyspnea and shortness of breath. Which of the following actions is the priority for the nurse to perform prior to administering oxygen?

Determine if the client has a history of COPD. According to evidence based practice the nurse should first assess if the client has COPD. Administering oxygen can worsen chronic hypercarbia in a client who has COPD

27. A nurse is checking the ECG Rhythm strip for a client who has a temporary pacemaker the nurse notes a spike or a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take

Document that depolarization has occurred. When a pacing stimulus is delivered to The ventricle a spike appears on the ECG Rhythm strip this spike should be followed by a QRS complex which indicates pacemaker capture or depolarization

75. A nurse is providing teaching to a client who has a new prescription for psyllium which of the following information should the nurse include in the teaching

Drink 240 milliliters of water after Administration

64. A nurse is assessing a client who has had a suspected cerebrovascular accident the nurse should place the priority on which of the following findings

Dysphasia because it indicates that the client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity Aphasia: Loss of ability to understand or express speech caused by brain damage. Ataxia: Neurological sign consisting of lack of voluntary coordination of muscle movements. Hemianopsia:

46. A nurse is planning care for a client who is scheduled for a thoracentesis which of the following interventions should the nurse include in the plan

Encourage the client to take deep breaths after the procedure to re-expand the lung

29. A nurses in an acute care facility is caring for a client who is at risk for seizures which of the following precautions should the nurse implement

Ensure that the client has a patent IV in the event that the client requires medication to stop seizure activity

56. A nurse is caring for a client who presents to a clinic for a one-week follow-up visit after hospitalization for heart failure based on the information in the clients chart which of the following findings should the nurse report to the provider Hystory and Physical: Discharge: Current: Wt: 66.7 kg (147 lb) Wt: 67.1 kg (148 lb) SaO2: 94% SaO2: 92% 2+ Pedal edema 1+ Pedal Edema HR 74/min HR: 55/min

Heart rate of 55 per minute is a significant drop from the clients Baseline of 74 permanent and it can indicate the development of digoxin toxicity Potassium: 3.5-4.1 Sodium: 135-145 Digoxin: 0.5-2.0 mg/ml

48. A charge nurse is instructing a newly licensed nurse about caring for a client who has MRSA which of the following statements by the newly licensed nurse indicates an understanding of the teaching

I will leave assessment equipment in the room to use on this client the nurse should follow contact precautions and use dedicated equipment when assessing the client to prevent cross-contamination with other clients

71. A nurse is providing teaching to a client who has asthma about the use of a metered dose inhaler the nurse should identify that which of the following client actions indicates an understanding of the teaching

Holding breath for 10 seconds after inhaling so that the medication can move deep into the Airways Breath in slowly and deeply while administering the medication for max effect. Rinse the plastic case and cap with warm running water once daily or soak in 1 pint of water with 2oz of vinegar once a week. Wait at least minute between puffs to allow adequate time for max effectiveness.

41. A nurse is caring for a client who has chronic glomerulonephritis with oliguria which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis

Hyperkalemia as a result of kidney failure because kidney failure results in decreased excretion of potassium

5. A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching question mark

I am dieting to lose weight. Excess weight cut creates increased abdominal pressure that can result in stress incontinence.

8. A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching?

I am taking this medication to increase my energy level. The goal of erythropoietin therapy is to increase the level of hematocrit and clients who have anemia. When the medication is effective the client should have a decreasing fatigue and an improvement and activity tolerance.

66. A nurse is providing teaching to a client who has Type 1 diabetes mellitus and a new prescription for insulin lispro which of the following statements by the client indicates an understanding of the teaching

I will need to take Lispro in addition to my other prescribed insulin because it is a rapid-acting insulin that the client can use in conjunction with an intermediate or long-acting insulin

72. A nurse is providing instructions to a client who has Type 2 diabetes mellitus and a new prescription for metformin which of the following statements by the client indicates an understanding of the teaching

I should take this medication with a meal to improve absorption and to minimize gastrointestinal distress Metformin decrease the amount of glucose produced in the liver and increases tissue sensitivity to insulin. Typically Pts Loose weight due to n & v. May rarely cause Rash.

47. A nurse is caring for a client who has a prescription for Enalapril the nurse should identify which of the following findings as an adverse effect of the medication

Orthostatic hypotension because dilation of arteries and veins causes orthostatic hypotension which is an adverse effect of Enalapril

84. nurse is providing discharge instructions to a client who has laryngeal cancer and received is receiving radiation treatment which of the following statements by the client indicates an understanding of the teaching

I will avoid direct exposure to the Sun because the client should avoid exposure of irradiated skin areas to the Sun for at least one year after completing radiation therapy skin in the radiation path is especially sensitive to sun damage.

1. A nurse is reviewing the medical record of a client who has systemic lupus erythematosus. Which of the following findings should the nurse expect?

Facial butterfly rash. R: A butterfly rash is a manifestation of SLE. It appears as a dry red rash on the clients cheeks and nose and can disappear during times of remission.

89. A nurse is teaching an older adult client about osteoporosis prevention the nurse should instruct the client that which of the following medications can increase her risk for developing osteoporosis

Fludrocortisone due to an increase in bone resorption by osteoclasts it can also reduce intestinal absorption of calcium Conjugated Estrogens decrease the clients' risk for developing osteoporosis. Enalapril-Bone marrow suppression Colchicine-Aplastic anemia

10. A nurse is preparing to present a program about atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? Select all that apply.

Follow a smoking cessation program maintain an appropriate weight eat a low-fat diet. Smoking cessation is an important lifestyle modification to prevent Arthur sclerosis and preventing obesity through diet and exercise can help prevent atherosclerosis. Eating a low fat diet decreases LDL cholesterol and can prevent atherosclerosis.

54. A nurse is caring for a client who has dka which of the following findings should indicate to the nurse at the client's condition is improving

Glucose of 272 because a glucose reading less than 300 indicates Improvement in the client's status. Normal Range PH: 7.35-7.45 PaCO2: 45-35 HCO3: 22-26 PaO2: 75-100 O2 Sat: 94-100%

70. A nurse is teaching to a client who has hypertension and a new prescription for Verapamil. Which of the following juices should the nurse instruct the client to avoid

Grapefruit because it inhibits the hepatic metabolism of the medication and then place the current client at risk for toxicity

14. A nurse is caring for a client who is post-operative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider?

HGB of 8. The nurse report and HGB level of 8 which is below the expected reference range and as an indicator of postoperative hemorrhage or anemia.

44. A nurse is assessing a client who has peripheral artery disease which of the following findings should the nurse expect

Hair loss on the lower legs the nurse should expect a client who is Peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth

43. A nurse is providing teaching to a client who has AIDS which of the following statements by the client indicates an understanding of the teaching

I will take my temperature once a day a client who has AIDS is immunocompromised and is at risk for infection the client should take his temperature daily to identify a temperature greater than 100 degrees which is an early manifestation of an infection

24. A nurse is providing discharge teaching to a client who is to self administer heparin subcutaneously. Which of the following responses by the client indicates an understanding of the teaching

I will use an electric razor to shave. Heparin is an anticoagulant that places the client at risk for bleeding therefore the nurse should instruct the client to use an electric razor when shaving to reduce the risk of cuts to the skin

9. A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands teaching?

I will wear clean graduated compression stockings everyday. The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand.

78. A nurse in an emergency department is caring for a client who has full thickness Burns over 20% of his total body surface area after ensuring a patent Airway and administering oxygen which of the following items should the nurse prepared to administer first

IV fluids to provide circulatory support

85. A nurse is caring for a client who has a positive culture for Clostridium difficile which of the following actions should the nurse take

Implement contact precautions for the client because direct contact is the mode of transmission

49. A nurse is caring for a client who recently had a stroke of the right hemisphere which of the following manifestations should the nurse expect

Impulsive behavior

73. A nurse is providing teaching to a client who has irritable bowel syndrome which of the following instructions should the nurse include in teaching

Increase fiber intake to at least 30 grams per day to produce bulky soft stools and establish regular bowel patterns Client should consume at least 2 L of water daily. Ginger tea is good for nausea not cramping Antacids are for gastric reflux and dyspepsia.

80. A nurse is reviewing the laboratory results of a client who has a new diagnosis of acute leukemia which of the following findings should the nurse identify as an expected finding

Increased white blood cell count due to overproduction of white blood cells by the bone marrow WBC count: 5-10,000 Hemoglobin: F 12-16 M 14-18 aPTT: 25-39 Seconds Amylase: 30-110 Units/L (Pancreatitis?)

69. A nurse is planning care for a client who was having a modified radical mastectomy of the right breast which of the following interventions should the nurse include in the plan of care

Instruct the client that the drain is removed when there is 25 milliliters of output or less over a 24-hour period the drain will remain in place for one to three weeks after surgery and we've removed when there is 25 milliliters of output or less in a 24-hour period Exercising Right Arm 24 hr after surgery. Elevate Right Arm on a pillow to promote lymphatic fluid return. Head elevated to at least 30 degrees to promote drainage from surgical site and for breathing.

4. A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days ago. Which of the following actions should the nurse take first after hearing the following sound?

Listen with the client on his left side. When providing nursing care the nurse should first use the least invasive intervention. Therefore after auscultating a murmur the first action the nurse should take is to place the client on his left side and listen to his heart again.

86. A nurse in a provider's office is assessing a client who has migraine headaches and is taking Feverfew to prevent her headaches the nurse should identify that which of the following client medications interact with Feverfew

Naproxen because they both impaired platelet aggregation and place the client at risk for bleeding Feverfew? medicinal plant traditionally used for the treatment of fevers, migraine headaches, rheumatoid arthritis, stomach aches, toothaches, insect bites, infertility, and problems with menstruation and labor during childbirth.

57. A nurse is assessing for compartment syndrome in a client who has a short leg cast which of the following findings should the nurse identify as a manifestation of this condition

Pain that increases with passive movement compartment syndrome results from a decrease in blood flow in the extremities because of a decrease in the muscle compartment size due to a cast that is too tight

52. a nurse is caring for a client who is experiencing supraventricular tachycardia upon assessing the client the nurse observes the following findings heart rate 200 per minute blood pressure 78 over 40 and respiratory rate 30 per minute which of the following actions should the nurse take

Perform synchronized cardioversion: For clients with Supraventricular Tachycardia. Defibrillate heart for ventricular tachycardia or ventricular fibrilation. CPR for pulseless or no breathing. Licocaine IV Bolus for Ventricular Dysrhythmia.

67. A nurse is providing medication teaching to a group of clients who have seizure disorders which of the following information should the nurse include about phenytoin

Phenytoin decreases the effectiveness of oral contraceptives because it stimulates the synthesis of hepatic enzymes which can decrease the activity of other medications including oral contraceptives

11. A nurse is caring for a client who is 12 hours post-operative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place a pillow between the clients legs. The nurse should place a pillow between the clients legs to prevent hip dislocation.

31. A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?

Place a pressure bag around the flush solution. The nurse should place a pressure bag around the flush solution because the pressure from an artery is greater than that of the line

15. A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use.

Place body weight on the crutches Advance the unaffected leg onto the stair Shift weight from the crutches to the unaffected leg and then bring the crutches and the affected leg up to the stair

42. A nurse is caring for a client who has bilateral pneumonia and an spo2 of 88% the client is dyspneic and productive cough and is using accessory muscles to breathe which of the following actions should the nurse take first

Place the client in a high Fowler's position

65. A nurse is planning care for a client who is post-operative following a parathyroidectomy which of the following actions should the nurse identify as the priority

Placed a tracheostomy tray at the bedside in case of Airway obstruction

32. A nurse is reviewing the medication history of a client who is to undergo allergy testing the nurse should instruct the client to discontinue which of the following medications before testing

Prednisone because it is a glucocorticoid that can cause the client to have false negative test results they should discontinue antihistamine medications several weeks prior to testing

87. A nurse in an emergency department is planning care for a client who has a flail chest on the right side following a motor vehicle crash which of the following actions should the nurse plan to take

Prepare the client for positive pressure ventilation to promote lung expansion and stabilize the pressure within the client's chest then there should also administer analgesics to alleviate pain while breathing to achieve optimal lung reexpansion

60. A nurse is assessing a client following the completion of hemodialysis which of the following findings is the nurses priority to report to the provider

Restlessness because using the Urgent vs. Non-urgent approach to client care the nurse to determine that the priority finding to report to the provider is restlessness which can be an indication of the client is experiencing disequilibrium syndrome which is caused by the rapid removal of electrolytes for the clients blood and can lead to dysrhythmias or seizures other manifestations include nausea vomiting fatigue and headache

28. A nurse is caring for a client who is eight hours post-operative following a total hip arthroplasty the client is unable to void on the bed pan Which of the following actions should the nurse take first

Scan the bladder with a portable ultrasound the first action should be using the nursing process which is assisting the client scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder

22. A nurse is providing follow-up care for a client who sustained a compound fracture three weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider

Sedimentation rate. And increased sedimentation rate occurs when a client has any type of inflammatory process such as osteomyelitis

79. A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for Gentamicin which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider

Serum creatinine because a client who has an elevated serum creatinine level should not receive Gentamicin because the medication is nephrotoxic Creatinine: M. Adult 0.6-1.2 F. Adult 0.5-1.1 in blood

68. A nurse is providing discharge instructions to a client who has active tuberculosis which of the following information should the nurse include in the instructions

Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures after three negative sputum cultures the client is no longer considered infectious Contagious no longer than 2-3 weeks after taking TB meds. F/U TB Evaluation: Chest XR, TB Test is no longer considered accurate after testing positive.

83. A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy to the nurse should recognize that which of the following complications is associated with long-term mechanical ventilation

Stress ulcers because of elevated levels of hydrochloric acid in the stomach. They increase risk for systemic infection and require pharm treatment Inhibition of blood return to the heat leading to decrease cardiac output and hypotension. Fluid retention due to decrease in cardiac output. Hyponatremia secondary to fluid retention from long term mechanical ventilation.

35. a nurse is caring for a client following excavation of her endotracheal tube 10 minutes ago. Which of the following findings should the nurse report to the provider immediately

Stridor. Using the Urgent vs. Non-urgent approach to client care the nurse should determine that the priority finding a Strider. Strider can indicate and narrowing Airway or possible obstruction caused by edema or laryngeal spasms the nurse should report the finding immediately Implement an intervention

33. A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for Omeprazole. The nurse should instruct the client that the medication provides Relief by which of the following actions

Suppressing gastric acid production. I love her soul is a proton pump inhibitor it relieves manifestations of gastric ulcers by suppressing gastric acid production

36. a nurse is caring for a client who had a nephrostomy tube inserted 12 hours ago. Which of the following findings should the nurse report to the provider

The client reports back pain the nurse should notify the provider if the client reports back pain which can indicate that the nephrostomy tube is dislodged or clogged

90. A nurse is teaching a client who has end-stage kidney disease about organ donation which of the following information should the nurse include in the teaching

The client who receives a kidney from a live donor has a lower rate of transplant rejection because the donor is often more medically compatible than a donor who is deceased

37. A nurse is assessing a client while suctioning the clients tracheostomy tube which of the following findings should indicate to the nurse that the client is experiencing hypoxia

The clients heart rate increases because hypoxia related to suctioning can cause the clients heart rate to increase if this occurs the nurse should discontinue the sectioning and immediately oxygenate the client with 100% oxygen the nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia

3. A nurse is assessing a client who has Graves disease. Which of the following images should indicate to the nurse that the client has exophthalmos?

The nurse should identify an outward protrusion of the eyes is exophthalmos a common finding of graves disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision including focusing on objects as well as pressure on the optic nerve.

26. Where would you palpate to assess for an inguinal hernia

The nurse should palpate at the right groin area because an inguinal hernia forms of the peritoneum which contains part of the intestine and can protrude into the scrotum in males

39. A nurse is teaching a client who has atrial fibrillation about the purpose of wearing a Holter monitor. Which of the following information should the nurse include in the teaching

This device can detect when you have an irregular heart rate because it reports and transmits electrical impulses of the heart and alerts the nurse to dysrhythmias myocardial injury or conduction defects a Holter monitor allows the client freedom of movement while cardiac activity is recorded

88. A nurse is preparing to assist with the insertion of a non tunneled percutaneous central venous catheter into a client's subclavian vein the nurse should plan to place the client in which of the following positions

Trendelenburg In this position with a trolled towel between the client's shoulder blades. This position facilitates the insertion of the catheter by dilating blood vessels of the client's neck and shoulders.

40. A nurse is providing discharge teaching to a client who has heart failure and a new prescription for potassium sparing diuretic which of the following information should the nurse include in the teaching

Try to walk at least 3 times per week for exercise because the development of a regular exercise routine can improve outcomes in clients who have heart failure

61. A nurse is caring for a client who is having a seizure which of the following interventions is the nurses priority

Turn the client to the side the greatest risk to this client is hypoxia from an impaired Airway, then follow with moving furniture away from the client and loosen clothing. Neurologic checks, such as pupillary response should be done after the seizure.

77. A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity which of the following instructions should the nurse include in the plan of care

Used crutches with rubber tips to prevent the client from slipping and decrease the risk of Falls

62. A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery the nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider

Warfarin because it is an anticoagulant which increases the client's risk for bleeding and is contraindicated for a client scheduled for I or Central Nervous System since surgery

17. A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication?

White blood cell count of 2000. This white blood cell count is below the expected reference range and indicates a risk for severe immunosuppression. WBC: RBC: Platelets:

45. A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management which of the following information should the nurse include in the teaching

You should increase your fiber intake to prevent constipation because opioids slow paracelsus in the gastrointestinal tract which causes constipation

19. A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make?

You will not be able to use sildenafil if you are taking nitroglycerin. The client should not use sildenafil when taking nitroglycerin because both medications can cause vasodilation and lead to significant hypotension

25. A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent Airway which of the following interventions is the priority

applying oxygen via face mask because the priority intervention is for the nurse to apply oxygen using a high-flow non-rebreather mask to deliver oxygen at 90 to 100%

59. A pacu nurse is assessing a client who is post-operative following a right nephrectomy the client's initial vital signs for heart rate 80 permanent blood pressure 130 over 70 respiratory rate 16 and temperature 96.8 which of the following Vital sign changes should alert the nurse the client might be hemorrhaging

heart rate of 110 per minute because one of the first signs of hemorrhage is an increase in the heart rate from the clients Baseline which occurs to compensate for blood BP: 120/880 HR: 60-100 RR: 12-20