ALL targeted

A nurse is providing discharge teaching for a client who has diabetes insipidus and has a new prescription for desmopressin nasal spray. Which of the following instructions should the nurse include in the teaching? a. "Depress the pump once before using the nasal spray for the first time." b. "Blow your nose gently prior to using the nasal spray." c. "Administer the nasal spray while in a side-lying position." d. "Notify the provider if you develop numbness or tingling around the mouth."

"Blow your nose gently prior to using the nasal spray." The nurse should instruct the client to blow his nose gently prior to use of the spray. This action prevents dilution of the medication with nasal secretions.

A nurse is providing discharge teaching for an older adult client who has mild diverticulitis. Which of the following statements by the client indicates an understanding of the teaching? -"I may experience right lower quadrant pain." -"I will remain active by working in my garden every day." -"I should eat foods that are low in fiber." -"I will use a mild laxative every day."

"I should eat foods that are low in fiber." The nurse should instruct the client who has diverticulitis to follow a low-fiber diet. When the inflammation subsides, the client should consume foods that are high in fiber.

A nurse is providing discharge for a client who has peptic ulcer disease and a new prescription for famotidine. Which of the following statements by the client indicates an understanding of the teaching? -"I should take this medication at bedtime." -"I should expect this medication to discolor my stools." -"I will drink iced tea with my meals and snacks." -"I will monitor my blood glucose level regularly while taking this medication."

"I should take this medication at bedtime." The nurse should instruct the client to take the medication at bedtime to inhibit the action of histamine at the H2-receptor site in the stomach.

A nurse in an outpatient clinic is teaching a client who has a diabetic foot ulcer about foot care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "I will let my feet air dry after washing." b. "I will wear sandals to allow air to circulate around my feet." c. "I will buy over-the-counter medicine to treat the calluses on my feet." d. "I will apply lotion to the dry areas of my feet but not between my toes."

"I will apply lotion to the dry areas of my feet, but not between my toes." Lotion can be used for dry areas of the feet, but the client should avoid applying lotion between the toes, as this area is prone to bacterial growth.

A nurse is providing discharge teaching for a client who has chronic hepatitis C. Which of the following statements by the client indicates an understanding of the teaching? -"I will avoid alcohol until I'm no longer contagious." -"I will avoid medications that contain acetaminophen." -"I will decrease my intake of calories." -"I will need treatment for 3 months."

"I will avoid medications that contain acetaminophen." A client who has hepatitis C should avoid medications that contain acetaminophen, which can cause additional liver damage.

A nurse is teaching a client who has type 1 diabetes mellitus about how to prevent complications during illness. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "I should stop taking my insulin if I feel nauseous." b. "I will test my urine for protein when I start to feel ill." c. "I will call my doctor if my blood sugar is more than 250." d. "I should check my blood sugar level every 8 hours."

"I will call my doctor if my blood sugar is more than 250 milligrams per deciliter." The client should call the provider if her blood glucose levels exceed 250 mg/dL during illness.

A nurse is providing discharge teaching for a client who has GERD. Which of the following statements by the client indicates an understanding of the teaching? -"I will decrease the amount of carbonated beverages I drink." -"I will avoid drinking liquids for 30 minutes after taking a chewable antacid tablet." -"I will eat a snack before going to bed." -"I will lie down for at least 30 minutes after eating each meal."

"I will decrease the amount of carbonated beverages I drink." The nurse should instruct the client to limit or eliminate fatty foods, coffee, cola, tea, carbonated beverages, and chocolate from his diet because they irritate the lining of the stomach.

A nurse is providing dietary teaching for a client who has a new diagnosis of celiac disease. Which of the following statements by the client indicates an understanding of the teaching? -"I can return to my regular diet when I am free of symptoms." -"I will need to avoid taking vitamin supplements while on this diet." -"I will eat beans to ensure I get enough fiber in my diet." -"I need to avoid drinking liquids with my meals while on this diet."

"I will eat beans to ensure I get enough fiber in my diet." Clients who have celiac disease must maintain a gluten-free diet which eliminates fiber-rich whole wheat products. Clients should eat beans, nuts, fruits, and vegetables to ensure an adequate intake of fiber.

To screen a client for pheochromocytoma, a nurse schedules a vanillylmandelic acid test. When teaching the client about this test, which of the following instructions should the nurse include? a. "Start fasting at midnight prior to the day of the test." b. "Begin the 24-hour urine collection with the first morning urination." c. "Take low-dose aspirin for pain during the testing period." d. "Restrict coffee intake 2 to 3 days prior to the test."

"Restrict coffee intake 2 to 3 days prior to the test." The client should avoid coffee and tea (even if they are decaffeinated), bananas, chocolate, and vanilla for 2 to 3 days prior to the test.

A nurse is developing a teaching plan for a client who had a thyroidectomy and takes a thyroid hormone replacement. Which of the following instructions should the nurse plan to include? a. "Take this medication on an empty stomach." b. "Take this medication with an antacid." c. "Change position slowly while taking this medication." d. "Limit your fluid intake while taking this medication."

"Take this medication on an empty stomach." To promote proper absorption, the client should take the medication on an empty stomach and not eat or drink anything for 30 to 60 min after taking it.

A nurse is caring for a client who has colorectal cancer and is receiving chemotherapy. The client asks the nurse why his blood is being drawn for a carcinoembryonic antigen (CEA) level. Which of the following responses should the nurse make? -"The CEA determines the current stage of your colon cancer." -"The CEA determines the efficacy of your chemotherapy." -"The CEA determines if the neutrophil count is below the expected reference range." -"The CEA determines if you are experiencing occult bleeding from the gastrointestinal tract."

"The CEA determines the efficacy of your chemotherapy." A provider uses the CEA level to determine the efficacy of the chemotherapy. The client's CEA levels will decrease if the chemotherapy is effective.

A nurse is teaching a client about glycosylated hemoglobin (HbA1c) testing. Which of the following statements should the nurse identify as an indication that the client understands the information about this test? a. "I need to fast after midnight the night before the test." b. "This test's result is a good indicator of my average blood glucose levels." c. "A level of 8 to 10 percent suggests adequate blood glucose control." d. "I will use my hemoglobin A1c level to adjust my daily insulin doses."

"This test's result is a good indicator of my average blood glucose levels." HbA1c reflects the client's glucose levels over a 120-day period, which is the life span of RBCs.

A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse expect? (Select all that apply) -Oral temperature 38.4° C (101.1° F) -WBC 6,000/mm3 -Bloody diarrhea -Nausea and vomiting -Right lower quadrant pain

-Oral temperature 38.4° C (101.1° F) -Nausea and vomiting -Right lower quadrant pain

A nurse is teaching a client who has an autoimmune disease about the adverse effects of long-term corticosteroid therapy. Which of the following effects should the nurse include? (select all that apply) a. Osteoporosis b. Moon-shaped face c. Increased risk of infection d. Hearing loss e. Weight loss

-Osteoporosis -Moon-shaped face -Increased risk of infection Osteoporosis is correct. Osteoporosis is an adverse effect of long-term corticosteroid therapy due to the suppression of bone formation and the acceleration of bone resorption that corticosteroid therapy can cause. Moon-shaped face is correct. Long-term corticosteroid therapy causes characteristics of iatrogenic Cushing's syndrome, including a moon-shaped face, a potbelly, and a buffalo hump. Increased risk of infection is correct. Increased risk of infection is an adverse effect of long-term corticosteroid therapy due to suppression of the immune system. It reduces the phagocytic actions of macrophages and neutrophils, thus increasing the risk of infection. Hearing loss is incorrect. Long-term corticosteroid therapy can cause cataracts and glaucoma, but it does not cause hearing loss. Weight loss is incorrect. Long-term corticosteroid therapy is more likely to cause weight gain due to the fluid and sodium retention these medications cause.

A nurse is caring for a client who has ulcerative colitis. The client has had several exacerbations over the past 3 years. Which of the following instructions should the nurse include in the plan of care to minimize the risk of further exacerbations? (Select all that apply) -Use progressive relaxation techniques -Increase dietary fiber intake -Drink two 240 mL (8 oz) glasses of milk per day -Arrange activities to allow for daily rest periods -Restrict intake of carbonated beverages

-Use progressive relaxation techniques. -Arrange activities to allow for daily rest periods. -Restrict intake of carbonated beverages.

A nurse is providing dietary teaching for a client who has chronic pancreatitis. Which of the following food selections by the client indicates an understanding of the teaching? -8 oz whole milk -One slice of beef bologna -1 oz cheddar cheese -1 cup sliced banana

1 cup sliced banana Foods that are high in fat can cause diarrhea for clients who have pancreatitis. One cup of sliced banana, which contains 0.49 g of fat, is a low-fat food option. Clients who have pancreatitis should consume a high-protein and low-fat diet with an adequate amount of carbohydrates and calories.

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of the instructions? A. "I should call my doctor if my vision gets worse" B. "I will take aspirin for eye discomfort" C. "I can blow my nose to clear out any drainage" D. "I can lift objects up to 20 lbs"

A. "I should call my doctor if my vision gets worse."- The client should expect an improvement in vision after the surgery, so the nurse should instruct the client to report negative changes in vision immediately. "I will take aspirin for eye discomfort."The client should avoid aspirin because it can cause bleeding in the eye. "I can blow my nose to clear out any drainage."The client should avoid blowing their nose because it can increase intraocular pressure. "I can lift objects up to 20 pounds."The client should avoid lifting objects heavier than 4.5 kg (10 lb) because it can increase intraocular pressure.

A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include? A. "Move your head slowly to decrease vertigo" B. "Apply warm packs to the affected ear during acute attacks" C. "Increase your intake of foods and fluids high in salt" D. "Take corticosteroid during acute attacks"

A. "Move your head slowly to decrease vertigo." The nurse should instruct the client to use slow head movements to keep from worsening the vertigo. "Apply warm packs to the affected ear during acute attacks."-Applying warm packs to the affected ear does not relieve the manifestations of Ménière's disease. Helpful interventions include drinking plenty of water, decreasing salt intake, and not smoking. "Increase your intake of foods and fluids high in salt."Clients who have Ménière's disease should avoid consuming foods and fluids that have a high sodium content because they cause fluid retention, which exacerbates the manifestations of Ménière's disease. "Take corticosteroids during acute attacks."Taking corticosteroids will not relieve the manifestations of Ménière's disease and can actually worsen them because these medications cause fluid retention. The client should take an antihistamine, such as meclizine, to minimize or stop the attack.

A nurse is caring for a client who reports a skin change. Which of the following findings should the nurse report to the provider? A. an asymmetrical papule that is pigmented B. A patch of silvery-white scales with a red epidermal base C. A collection of irregular, dry papules that are black D. An elevated red lesion that arises from a scar

A. An asymmetrical papule that is pigmented The nurse should identify an asymmetrical papule that is pigmented as an indication of malignant melanoma. The nurse should report the client's skin change to the provider.

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect? (Select all that apply) A. Crepitus with joint movement B. Decreased range of motion of the affected joint C. Low-grade fever D. Spongy tissue over the joints E. Joint pain that resolves with rest

A. Crepitus with joint movement: Osteoarthritis is a degenerative joint disease. Crepitus, a grating sound, is an expected finding with clients who have osteoarthritis as loosened bone and cartilage move around in the fluid inside the joint. B. Decreased range of motion of the affected: Decreased range of motion is an expected finding with clients who have osteoarthritis because the client's pain limits movement. E. Joint pain that resolves with rest. Joint pain that resolves with rest is an expected finding with clients who have osteoarthritis. A client who has osteoarthritis experiences increased pain with activity and decreased pain with rest. ---------- Low-grade fever is incorrect. Osteoarthritis does not cause systemic manifestations. Rheumatoid arthritis causes many systemic manifestations, including low-grade fever, weakness, anorexia, and paresthesias. Spongy tissue over the joints is incorrect. Spongy joint tissue is an expected finding with rheumatoid arthritis, which is an inflammatory disease, not a degenerative disease.

A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following client statements indicates an understanding of the teaching? A. I will avoid being in large crowds while taking this medication B. I should expect symptoms to subside in 1 to 2 weeks after starting this medication C. I will increase my intake of vitamin D while taking this meedication D. I should expect experience constipation while taking this medication

A. I will avoid being in large crowds while taking this medication The nurse should instruct the client to avoid crowds when taking methotrexate. Methotrexate can cause leukopenia due to bone marrow suppression, which can increase the client's risk for infection.

A nurse is providing teaching to a client who takes an oral contraceptive and has a new prescription for amoxicillin. Which of the following statements by the client indicates an understanding of the teaching? A. I will use a backup method of birth control while I am taking this medication B. I should take this medication on an empty stomach C. I should expect to have constipation while taking this medication D. I will keep taking this medication until I feel better

A. I will use a backup method of birth control while I am taking this medication The nurse should inform the client that antibiotics accelerate the elimination of oral contraceptives, making them less effective.

A nurse is providing teaching to a group of clients regarding skin cancer prevention. Which of the following risk factors should the nurse include in the teaching? A. Light skin pigmentation B. Psoriasis C. History of frostbite D. Immunodeficiency disorder

A. Light skin pigmentation The nurse should inform the clients that light skin pigmentation is a risk factor for the development of skin cancer

A nurse is planning care for a client who has a closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following intervention is the nurse's priority? A. Maintain a PaCO2 of approx. 35 mmHg B. Provide small doses of fentanyl via bolus for pain management C. Measure body temperature every 1-2hr

A. Maintain a PaCO2 of approx. 35 mmHg The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority action is to maintain the PaCO2 at approximately 35 mm Hg to prevent hypercarbia and subsequent vasodilation effects that lead to increase in intracranial pressure.

A nurse in an emergency department is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse expect to administer? A. Osmotic diuretics via IV bolus B. Mydriatic ophthalmic drops C. Corticosteroid ophthalmic drops D. Epinephrine via IV bolus

A. Osmotic diuretics via IV bolus The nurse should expect to administer prescribed osmotic diuretics, such as mannitol, to reduce intraocular pressure and prevent damage to the eye. Mydriatic ophthalmic dropsClients who have primary angle-closure glaucoma should not receive mydriatic ophthalmic drops because they cause pupillary dilation. Instead, the nurse should expect to administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor. Corticosteroid ophthalmic drops-Corticosteroid ophthalmic drops are used for inflammatory conditions of the eye, such as conjunctivitis. There is no indication for clients who have primary angle-closure glaucoma to receive corticosteroid ophthalmic drops. Instead, the nurse should expect to administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor. Epinephrine via IV bolusClients who have primary angle-closure glaucoma should not receive epinephrine-containing medications because they cause vasoconstriction. Instead, the nurse should expect to administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor.

A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure? A. Restlessness B. Dizziness C. HPTN D. Fever

A. Restlessness- Behavioral changes, such as restlessness and irritability, are early manifestations of increased intracranial pressure. DizzinessAlthough dizziness might be present after head trauma, it is not a manifestation of increased intracranial pressure. HypotensionAlthough hypotension might be present after head trauma, especially if the client is experiencing hypovolemic or neurogenic shock, it is not a manifestation of increased intracranial pressure. Cushing's triad of hypertension, bradycardia, and a widening pulse pressure is a late manifestation of increased intracranial pressure. FeverAlthough a client who has head trauma can develop fever, it is either in response to infection or due to hypothalamic damage, not due to increased intracranial pressure.

A nurse is assessing a client who has HIV which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS? A. small, purple colored skin lesions B. Fever and diarrhea lasting longer than 1 month C. Persistent, generalized lymphandenopathy D. CD4-T cells decreased to 750 cells

A. Small purple colored skin lesions the nurse should identify the presence of small, purple-colored skin lesions as an indication that the client has acquired Kaposi's sarcoma, which is an AIDS-defining illness

A nurse is caring for a client who has neutropenia. Which of the following findings indicates a need for intervention? A. The client's grandchild is visiting and telling the client about the first day of kindergarten B. The client has a grilled ham and cheese sandwich, a banana, and yogurt on their lunch tray C. The client's family brings in a silk flower arrangement D. The client's assistive personnel places paper cups and plastic utensils in the client's room

A. The client's grandchild is visiting and telling the client about the first day of kindergarten The nurse should limit the client's visitors to healthy adults. A visit from a child who is attending school can place the client at risk for infection due to the client's immunocompromised status.

A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell wile at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to administer? A. Tissue plasminogen activator B. Recombinant factor VIII C. Nitroglycerin D. Lidocaine

A. Tissue plasminogen activator- Tissue plasminogen activator is a thrombolytic agent that should dissolve the blood clot that caused the stroke. Recombinant factor VIII- Recombinant factor VIII helps manage the manifestations of hemophilia. Nitroglycerin-Nitroglycerin is a coronary and venous vasodilator that treats angina. Lidocaine- Lidocaine is an antidysrhythmic agent that treats ventricular dysrhythmias

A nurse is reviewing the daily laboratory results for a female client who has acute leukemia. Which of the following values is an expected findings? A. WBC count 21000 B. Hgb 14 C. Hct 40% D. Platelets 170,000

A. WBC count 21000 The nurse should expect a client who has acute leukemia to have an elevated WBC count

A nurse is assessing a client who has a new prescription for clindamycin to treat acute pelvic inflammatory disease. the nurse should report which of the following findings to the provider immediately? A. watery diarrhea B. Vaginitis C. Furry tongue D. Nausea and vomiting

A. Watery diarrhea The greatest risk to this client is pseudomembranous colitis, which is manifested by watery diarrhea. Therefore, the priority finding is diarrhea. The nurse should report this finding to the provider immediately and discontinue the medication.

A nurse is teaching a client about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should explain that the purpose of the test is to assess for which of the following disorders? a. Diabetes insipidus b. Hyperthyroidism c. Pheochromocytoma d. Addison's disease

Addison's disease The nurse should instruct the client that the ACTH stimulation test is the standard test for Addison's disease. It measures the cortisol response to ACTH. The response is absent or very decreased in clients who have primary adrenal insufficiency.

A nurse is managing the care of a client who is postoperative and has acute adrenal insufficiency. Which of the following actions should the nurse take? a. Administer IV hydrocortisone sodium. b. Give oral spironolactone. c. Infuse 1 unit of platelets. d. Restrict daily fluid intake.

Administer IV hydrocortisone sodium. Hydrocortisone sodium is necessary to replace the cortisol deficiency that occurs with adrenal insufficiency.

A nurse is reviewing the laboratory results of a client who has hepatic cirrhosis. Which of the following laboratory findings should the nurse report to the provider? -Albumin 4.0 g/dL -INR 1.0 -Direct bilirubin 0.5 mg/dL -Ammonia 180 mcg/dL

Ammonia 180 mcg/dL An ammonia level of 180 mcg/dL is above the expected reference range of 10 to 80 mcg/dL. The nurse should report an increased ammonia level because it can indicate portal-systemic encephalopathy.

A nurse is caring for a client who has GERD and a new prescription for metoclopramide. The nurse should plan to monitor for which of the following adverse effects? -Thrombocytopenia -Hearing loss -Hypersalivation -Ataxia

Ataxia The nurse should plan to monitor the client for extrapyramidal symptoms, such as ataxia, and should report any of these findings to the provider.

A nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. Which of the following statements indicates that the client understands the teaching? A. "I will ask my partner to give the injection in the same spot each time" B. "I will avoid going to the store when it is crowded" C. "I will see relief of my symptoms in about 1 wk" D. " I will exercise rigorously while taking this medication"

B. "I will avoid going to the store when it is crowded."- Clients who are prescribed this medication are instructed to avoid crowds and individuals who have infection. "I will ask my partner to give the injection in the same spot each time." Clients are instructed to rotate the site of injection because local skin reactions are common. "I will see relief of my symptoms in about 1 week."Clients are instructed that it may take up to 6 months for the immune response to become evident. "I will exercise rigorously while taking this medication."Clients who have multiple sclerosis are instructed to avoid activities that increase their temperature, which leads to fatigue.

A nurse is teaching a client who has osteoporosis and has a new prescription for alendronate. Which of the following information should the nurse include in the teaching? A. "Take this medication with 8 oz of milk" B. "Remain upright for 30 min after taking this medication" C. "Wait 1 hr after taking other medications to take alendronate" D. "Take vitamin C to promote absorption of this medicaton"

B. "Remain upright for 30 minutes after taking this medication."- To prevent esophagitis or esophageal ulcers, which can result from alendronate therapy, the client should sit upright for 30 min after taking this medication. "Take this medication with 8 ounces of milk." The nurse should instruct the client to take alendronate with 240 mL (8 oz) of water, not milk. Foods or beverages containing calcium can reduce medication absorption. "Wait 1 hour after taking other medications to take alendronate."The nurse should instruct the client to take alendronate first thing in the morning, at least 30 min before other medications. "Take vitamin C to promote absorption of this medication."Vitamin C intake does not increase alendronate absorption and some sources, such as orange juice, decrease absorption. However, the nurse should encourage the client to take vitamin D, which promotes calcium absorption.

A nurse is performing a breast examination on a female client who is pregnant. Which of the following findings should the nurse report to the provider? A. Slight asymmetrical breast size B. Breast tissue with an orange-peel appearance C. Nipple inversion of one breast since puberty D. Elevated Montgomery's glands

B. Breast tissue with an orange-peel appearance The nurse should report an orange-peel appearance of the client's skin because this can indicate a blockage of lymph channels which is a manifestation of advanced breast cancer

A nurse is providing teaching to a client who is scheduled for a papanicolaou (pap) test. The nurse should inform the client that the Pap test is used to screen for which of the following? A. uterine cancer B. cervical cancer C. ovarian cysts D.fibroids

B. Cervical cancer the nurse should inform the client that a pap test is used to screen for cervical cancer

A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first? A. Reposition the client B. Check the position of the weights and ropes C. Administer a muscle relaxant D. Provide distraction

B. Check the position of the weights and ropes. The first action the nurse should take when using the nursing process is to assess the client. The nurse should first check the position of the weights and ropes to investigate the cause of the muscle spasms. The weights might be too heavy, or the nurse might need to realign the client Reposition the client.- The nurse should reposition the client to realign him and try to relieve his muscle spasms. However, there is another action the nurse should take first. Administer a muscle relaxant.- The nurse should administer a muscle relaxant to minimize the client's muscle spasms. However, there is another action the nurse should take first. Provide distraction.- The nurse should provide sensory stimulation to help the client keep his focus away from the pain of the spasms. However, there is another action the nurse should take first.

A nurse is assessing a client who has systemic lupus erythematosus. which of the following findings should the nurse expect? select all that apply A. subcutaneous nodules B. Decreased urine output C. Renal calculi D. Butterfly rash E. Joint inflammation

B. Decreased urine output D. Butterfly rash is correct E. Joint inflammation ------ a = rheumatoid arthritis c = lupus nephritis, not renal calculi is a manifestations of SLE.

A nurse in an emergency department is assessing a newly admitted client. Which of the following actions places the client at increased risk for contracting hepatitis B? A. residing in an institutional setting B. Engaging in unprotected sexual intercourse C. Working with hazardous chemical waste materials D. Traveling to a foreign country

B. Engaging in unprotected sexual intercourse A client who engages in unprotected sexual intercourse is at increased risk because hepatitis B is transmitted by sexual contact.

a nurse is providing discharge teaching to a client who has HIV. Which of the following statements by the client indicates an understanding of the teaching? A. I will clean the bathroom surfaces with full strength bleach B. I should discard open beverages that have been unrefrigerated for 1 hr C. I should wash laundry that is soiled with a body fluid in cool water D. I will work in the garden for exercise

B. I should discard open beverages that have been unrefrigerated for 1 hr The nurse should instruct the client to discard beverages that have been unrefrigerated for 1 hr. Bacteria can grow in open, unrefrigerated beverages, which places the client at risk for infection.

A nurse is caring for a client who has viral pneumonia. Which of the following findings should the nurse report to the provider immediately? A. Negative blood culture B. Left shift in WBC differential C. Oxygen saturation 93% D. Crackles heard on auscultation

B. Left shift in WBC differential When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a left shift in the client's WBC differential, which indicates that the pneumonia is of bacterial origin, rather than viral. The left shift can be a manifestation of sepsis, and the nurse should report this finding to the provider.

A nurse is reviewing the laboratory report for a client who has hodgkin's lymphoma. Which of the following findings should the nurse expect? A. overgrowth of B-lymphocyte plasma cells B. Reed-Sternberg cells C. Epstein-Barr virus D. Overproduction of blast phase cells

B. Reed sternberg cells The nurse should expect to find Reed-Sternberg cells, which are cancer cells specific to a client who has Hodgkin's lymphoma, in the client's lymph nodes.

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition? A. Encourage the client to use the Valvalsa maneuver B. Stroke the client's inner thigh C. Perform the Crede maneuver D. Administer a diuretic

B. Stroke the client's inner thigh The nurse should stimulate micturition by stroking the client's inner thigh. Other techniques include pinching the skin above the groin and providing digital anal stimulation. Perform the Credé maneuver.The nurse should apply direct pressure over the client's bladder, also known as the Credé maneuver, to express urine from a flaccid bladder. It is not effective for clients who have a spastic bladder due to the spasticity of the external sphincter. Administer a diuretic.Antispasmodics such as oxybutynin, rather than diuretics, can be effective for treating mild spastic bladder problems. Encourage the client to use the Valsalva maneuver.-The nurse should encourage the client to hold their breath and bear down, also known as the Valsalva maneuver, to express urine from a flaccid bladder. It is not effective for clients who have a spastic bladder due to the spasticity of the external sphincter.

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect? A. Unilateral joint involvement B. Ulnar deviation C. Fracture of the spine D. Decreased sedimentation rate

B. Ulnar deviation- A client who has rheumatoid arthritis can experience inflammation in the hand joints that can make them susceptible to deformity from daily use. Ulnar deviation, or lateral deviation of the fingers, can occur from opening jars and other similar motions. Unilateral joint involvement Rheumatoid arthritis usually occurs bilaterally and symmetrically. Osteoarthritis usually occurs unilaterally. Fractures of the spineCompression fractures of the spine are more common in clients who have osteoporosis. Decreased sedimentation rateA client who has rheumatoid arthritis will have an increased sedimentation rate due to the body's response to the inflammatory connective tissue disorder.

A nurse is teaching a client who has diabetes mellitus. Which of the following should the nurse include as an expected finding of diabetic ketoacidosis (DKA)? a. Decreased urine output b. Weight gain of 0.45 kg (1 lb) in 24 hr c. Rapid, shallow respirations d. Blood glucose levels above 300 mg/dL

Blood glucose levels above 300 mg/dL Blood glucose levels above 300 mg/dL are an expected finding with DKA. Levels above 600 mg/dL are an expected finding with hyperglycemic-hyperosmolar state.

A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report to the provider? -Spider angiomas -Peripheral edema -Bloody stools -Jaundice

Bloody stools The greatest risk to the client who has cirrhosis of the liver is hemorrhagic shock due to bleeding in the esophageal varices. Therefore, bloody stools is the priority finding to report to the provider.

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect? -Bloody diarrhea -Board-like abdomen -Periumbilical cyanosis -Increased bowel sounds

Board-like abdomen A board-like, distended abdomen, accompanied by extreme pain and tenderness, is an expected finding in a client who has peritonitis.

A nurse is teaching a client who has Parkinson's disease and is prescribed carbidopa-levodopa. Which of the following client statements indicates an understanding of the teaching? A. "I should expect an increase in my blood pressure while taking this medication" B. "I should take this medication 2 hr after meals to increase absorptions" C. "I should expect that this medication can cause me to be drowsy" D. "I should expect this medication to be effective within 48 hrs"

C. "I should expect that this medication can cause me to be drowsy." Drowsiness is a known adverse effect of carbidopa-levodopa; therefore, clients are taught to avoid heavy machinery and driving if they experience drowsiness. "I should expect an increase in my blood pressure while taking this medication."Orthostatic hypotension is an adverse effect of carbidopa-levodopa. "I should take this medication 2 hours after meals to increase absorption."-Carbidopa-levodopa should be administered before meals to increase absorption and transport the medication across the blood-brain barrier. "I should expect this medication to be effective within 48 hours." The nurse should inform the client that the medication can take 2 to 3 months to take effect.

A nurse is planning discharge teaching for a client who is receiving chemotherapy and has bone marrow suppression. Which of the following instructions should the nurse plan to include in the teaching? A. Take aspirin for minor aches and pains B. Clean your toothbrush with warm water weekly C. Bathe with an antimicrobial soap twice per day D. Wear clothing that will minimize sun exposure

C. Bathe with an antimicrobial soap twice per day The nurse should instruct the client to bathe twice per day with an antimicrobial soap to decrease their exposure to micro-organisms. A client who has bone marrow suppression is at increased risk for infection

A nurse is providing teaching to a client who has an allergy to peanuts. Which of the following instructions is the priority to include in the teaching? A. Inform other health care professionals of the allergy B. Wear a medical identification tag C. Carry an emergency anaphylaxis kit D. Keep a food diary

C. Carry an emergency anaphylaxis kit the greatest risk to the client is injury or death from an anaphylactic reaction. therefore, the priority instruction for the client is to be prepared for emergency treatment carrying an emergency anaphylaxis kit

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take? A. Assess the client's neurologic status every 8 hr B. Initiate droplet precautions C. Check capillary refill at least every 4 hr D. Place the client in a well-lit environment

C. Check capillary refill at least every 4hr-The nurse should perform a complete vascular assessment at least every 4 hr to monitor for vascular compromise Place the client in a well-lit environment. The nurse should minimize the client's exposure to light from windows and overhead lights because photophobia, or light sensitivity, is a manifestation of viral meningitis. Assess the client's neurologic status every 8 hr.The nurse should assess the client's vital signs and neurologic status at least every 2 to 4 hr. Initiate droplet precautions.-The nurse should implement droplet precautions for clients who have bacterial meningitis. Standard precautions are sufficient for clients who have viral meningitis.

A nurse is caring for a client who has an elevated prostate-specific antigen level. The nurse should anticipate that the client will undergo which of the following diagnostic tests? A. palpation of testes B. Human chorionic gonadotropin level C. Digital rectal examination D. Pelvic ultrasound

C. Digital rectal examination The nurse should recognize that a digital rectal examination is used to determine the size and consistency of the prostate, assisting with the differentiation between benign prostatic hypertrophy and prostate cancer

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to take? A. Apply pressure dressing to the site for 8 hr B. Restrict the client's fluid intake for 24 hr C. Ensure that the client lies flat for up to 12 hr D. Inform the client that neck stiffness is an expected outcome of the procedure

C. Ensure that the client lies flat for up to 12 hr.-The client should lie flat for up to 12 hr to prevent cerebrospinal fluid leakage from the puncture site, which can cause a headache Apply a pressure dressing to the site for 8 hr.The nurse should apply pressure to the site and then apply an adhesive bandage, not a pressure dressing. Restrict the client's fluid intake for 24 hr.The client should increase fluid intake to replace the cerebrospinal fluid the provider removed during the procedure. Inform the client that neck stiffness is an expected outcome of the procedure. The nurse should instruct the client to report complications of a lumber puncture such as voiding difficulties, fever, stiffness of the back or neck, nausea, and vomiting.

A nurse is planning an education program about testicular cancer for a group of male adolescents. which of the following information should the nurse include? A. Testicular cancer is more common in males who are older than 65 B. With early treatment, the survival rate is 50% C. Examine the testicles immediately after showing D. Schedule an annual ultrasound to screen for testicular cancer

C. Examine the testicles immediately after showing The client should perform a testicular self-examination on a monthly basis by examining the testicles after a bath or shower to allow for easier palpatation

A nurse is caring for a client who has a retinal detachment. which of the following findings should the nurse expect? A. Photophobia B. Complete vision loss C. Flashes of bright light D. Cloudiness of the lends

C. Flashes of bright light The nurse should expect a client who has a retinal detachment to see flashes of bright light or floating dark spots in the affected eye as the retinal layers separate. Photophobia - The nurse should expect photophobia in a client who has a migraine headache. Complete vision loss -The nurse should expect a client who has a retinal detachment to have some visual field loss in the area of the detachment, but complete vision loss is not an expected finding. Cloudiness of the lens- The nurse should expect a client who has cataracts to experience cloudiness of the lens

A nurse is providing teaching to a client who has systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching? A.. I should use a sunscreen with a SPF of at least 15 B. Long-term immunosuppressive therapy could cure this disease C. I should wear gloves when it is cold outside D. SLE should not affect my lungs or breathing

C. I should wear gloves when it is cold outside Raynaud's phenomenon commonly accompanies SLE and can cause painful vasoconstriction in the client's fingers when exposed to cold temperatures

A nurse is assessing a client who had a right hemisphere stroke. Which of the following neurologic deficits should the nurse expect? A. Aphasia B. Right-sided neglect C. Impulsive behavior D. Inability to read

C. Impulsive behavior- The nurse should expect clients who had a right hemispheric stroke to demonstrate impulsive behavior, poor judgment, and lack of awareness of neurologic deficits. AphasiaClients who had a left hemispheric stroke are likely to have aphasia. Right-sided neglectClients who had a right hemispheric stroke are likely to have neurologic deficits on the left side of the body, not the right side. The nurse should expect the client to be unaware of and unable to move the left side of the body. Inability to read Clients who had a left hemispheric stroke are likely to have difficulty reading due to the inability to discriminate different letters and words.

A nurse is caring for a client who has multiple sclerosis. Which of the following should the nurse expect? A. Hypoactive deep-tendon reflexes B. Ascending paralysis C. Intention tremors D. Increased lacrimation

C. Intention tremors- Clients who have multiple sclerosis are at risk for motor dysfunction, with intention tremors, poor coordination, and loss of balance. Hypoactive deep-tendon reflexes- Clients who have multiple sclerosis have hyperactive deep-tendon reflexes. Ascending paralysis- Clients who have Guillain-Barré syndrome are at risk for ascending paralysis. Increased lacrimation-Increased lacrimation, or tearing of the eyes, is an expected finding of myasthenia gravis during a cholinergic crisis.

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority? A. Provide frequent rest period throughout the day B. Administer pain medication on a regular schedule C. Monitor pulse oximetry findings D. Administer baclofen for spasticity

C. Monitor pulse oximetry findings.- The greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles. Therefore, the priority intervention is to monitor the client's oxygen saturation to identify respiratory compromise as soon as possible. Provide frequent rest periods throughout the day.The nurse should provide frequent rest periods throughout the day because the client's fatigue will increase as the disease progresses. However, this is not the priority intervention. Administer pain medication on a regular schedule.The nurse should administer pain medication on a regular schedule to keep the client's pain level under control. However, this is not the priority intervention. Administer baclofen for spasticity. The nurse should administer baclofen to manage spasticity that can interfere with self-care. However, this is not the priority intervention

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take? A. Remind the client that the surgery removed the limb B. Change the dressing on the client's residual limb C. Request a prescription for gabapentin for the client D. Elevate the client's residual limb above the heart level

C. Request a prescription for gabapentin for the client. The nurse should request a prescription for a nonopioid medication to help minimize phantom limb pain. Gabapentin is an oral antiepileptic medication that is effective for treating sharp, burning, phantom limb pain. Remind the client that the surgery removed the limb.-It is not therapeutic for the nurse to remind the client that the limb is gone because it does not address the client's pain. Change the dressing on the client's residual limb.Changing the dressing on the client's residual limb does not address the client's pain. Elevate the client's residual limb above heart level. The nurse should only elevate the client's residual limb above the heart level within the first 48 hr following the surgery. After that time, doing so can cause a hip or knee flexion contracture.

A nursing is educating a client who is scheduled for a kidney transplant. Which of the following information about hyperacute rejection should the nurse include in the teaching? A. Hyperacute rejection can occur during the first few weeks after the transplant B. If hyperacute rejection occurs, the kidney can become enlarged C. The organ will need to be removed if hyperacute rejection occurs D. Immunosuppressive therapy is given to reverse hyperacute rejection

C. The organ will need to be removed if hyperacute rejection occurs Removing the transplanted organ is the only treatment for hyperacute rejection, due to the widespread clotting cascade that leads to ischemic necrosis of the transplant kidney

A nurse is caring for a client who is admitted with enlarged lymph nodes and a fever. To confirm a diagnosis of bacterial pharyngitis, the nurse should anticipate which of the following diagnostic tests? A. indirect laryngoscopy B. Chest xray C. Throat culture D. Monospot test

C. Throat culture Nurse should recongnize that a throat culture is used to confirm a diagnosis of bacterial pharyngitis by identifying specific micro-organisms present in the pharynx

A nurse is caring for a client who has HIV. Which of the following laboratory findings should suggest to the nurse that medication therapy is effective? A. WBC count 3500 B. Lymphocyte 1,400 C. Decreased viral load D. Low CD4/CD8 ratio

C. decreased viral load The nurse should recognize that a client who has HIV and is receiving medication therapy should display a decreasing viral protein amount in the blood, indicating a positive response to the medication therapy.

A nurse is assessing a client who has adrenal insufficiency. Which of the following findings should the nurse expect? a. Moon-shaped face b. Weight gain c. Calcium 12.8 mg/dL d. Sodium 150 mEq/L

Calcium 12.8 mg/dL A client who has adrenal insufficiency has a calcium level above the expected reference range.

A nurse is assessing a client who has diabetes mellitus and reports feeling anxious. Which of the following findings should the nurse expect if the client is hypoglycemic? a. Rapid, deep respirations b. Cool, clammy skin c. Abdominal cramping d. Orthostatic hypotension

Cool, clammy skin Hypoglycemia causes cool, clammy skin, in addition to anxiety, nervousness, tachycardia, and confusion.

A nurse is performing a pain assessment for a client who is postoperative. Which of the following findings should the nurse use to determine the severity of the client's pain? A. Client's vital sign changes B. Client's report of the type of pain C. Client's nonverbal communication D. Client's report of pain on a pain scale

D. Client's report of pain on a pain scale- The nurse should use a client's report of pain on a standardized pain scale to determine the severity of the client's pain. Client's vital sign changes- A change in vital signs can identify that pain is present, but the nurse should use another finding to determine the severity of the client's pain. Client's report of the type of pain- report of the type of pain identifies the character of the pain, such as sharp or dull, but the nurse should use another finding to determine the severity of the client's pain. Client's nonverbal communication-Facial grimacing can identify that pain is present, but the nurse should use another finding to determine the severity of the client's pain.

A nurse is teaching a client and her family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements should the nurse identify as an indication that the family understands the teaching? A. "There is a test for Alzheimer's disease that can establish a reliable diagnosis" B. "The goal of medication therapy is to reverse the degenerative changes that can occur in brain tissue" C. "Early manifestations of Alzheimer's disease include mild tremors and muscular rigidity" D. "The medications that treat Alzheimer's disease can help delay cognitive changes"

D. "The medications that treat Alzheimer's disease can help delay cognitive changes."-Medications that treat Alzheimer's disease enhance the availability of acetylcholine, which can slow cognitive decline in some clients. "There is a test for Alzheimer's disease that can establish a reliable diagnosis."There is no specific test for identifying Alzheimer's disease, except direct examination of the brain on autopsy. Providers diagnose Alzheimer's disease based on manifestations and by ruling out other diseases. "The goal of medication therapy is to reverse the degenerative changes that can occur in brain tissue."None of the medications currently available reverse the course of Alzheimer's disease. "Early manifestations of Alzheimer's disease include mild tremors and muscular rigidity."Early manifestations include short-term memory loss, forgetfulness, and a shortened attention span. Mild tremors and muscular rigidity are manifestations of Parkinson's disease.

A nurse is caring for four clients. Which of the following clients is at the greatest risk for pneumonia? A. A school-age child who has a history of asthma B. a young adult client who is living in a college dormitory C. A middle adult client who is using an incentive spirometer following surgery D. An older adult client who has dysphagia

D. An older adult client who has dysphagia An older adult client who has dysphagia is at the greatest risk for pneumonia due to the increased risk for aspiration when eating

A nurse is providing teaching to a client who has rheumatoid arthritis and reports persistent pain. Which of the following responses should the nurse make? A. Take a cool bath in the evening B. Exercise every other day C. Use pillows to support your joints while in bed D. Ask a friend or a family member to help with household chores

D. Ask a friend or a family member to help with household chores The nurse should

A nurse is providing teaching to a client who has Hodkin's lymphoma and is undergoing external radiation treatment. Which of the following instructions should the nurse include? A. Use an antibacterial soap to cleanse the skin B. Wash the ink marking off when showering C. Rub the skin with a towel when drying D. Avoid direct sun exposure to the skin

D. Avoid direct sun exposure to the skin The nurse should instruct the client to avoid sun exposure because the client's skin is sensitive to sunburn due to the external radiation.

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider? A. Glasgow Coma Scale score of 15 B. Intracranial pressure reading of 15 mm Hg C. Ecchymosis at base of skull D. Clear drainage from nose

D. Clear drainage from nose- Clear drainage from the nose indicates that cerebrospinal fluid is leaking from the skull fracture. This places the client at risk for meningeal infection because micro-organisms have access to the cranium through the nose and the tear in the dura. The nurse should report this finding to the provider. Glasgow Coma Scale score of 15- A Glasgow Coma Scale score of 15 indicates intact neurologic functioning and does not need to be reported to the provider. Intracranial pressure reading of 15 mm Hg-An intracranial pressure reading of 15 mm Hg is at the upper limit of the expected reference range and does not need to be reported to the provider. Ecchymosis at base of skull- A client who has a basilar skull fracture is likely to have ecchymosis at the base of the skull from a contusion and this finding does not need to be reported to the provider.

A nurse is teaching a client how to prepare for a colonoscopy. Which of the following instructions should the nurse include in the teaching? -Begin drinking the oral liquid preparation for bowel cleansing on the morning of the procedure. -Drink full liquids for breakfast the day of the procedure, and then take nothing by mouth for 2 hr prior to the procedure. -Drink clear liquids for 24 hr prior to the procedure, and then take nothing by mouth for 6 hr before the procedure. -Drink the oral liquid preparation for bowel cleansing slowly.

Drink clear liquids for 24 hr prior to the procedure, and then take nothing by mouth for 6 hr before the procedure. The nurse should instruct the client to drink clear liquids for 24 hr prior to the colonoscopy to promote adequate bowel cleansing. Maintaining NPO status for 4 to 6 hr prior to the colonoscopy preserves the bowel's cleansed state.

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110mm Hg. Which of the following actions should the nurse take first? A. Administer hydralazine via IV bolus B. Loosen the client's clothing C. Empty the client's bladder D. Elevate the head of the client's bed

D. Elevate the head of the client's bed.- These assessment findings indicate that the client is experiencing autonomic dysreflexia and is at greatest risk for possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from a supine to an upright position, which will result in rapid postural hypotension. Administer hydralazine via IV bolus.- The nurse should administer hydralazine, a potent vasodilator, to lower the client's blood pressure. However, there is another action the nurse should take first. Loosen the client's clothing.-The nurse should loosen the client's clothing because body temperature and tactile stimulation are triggers of autonomic dysreflexia. However, there is another action the nurse should take first. Empty the client's bladder.- The nurse should empty the client's bladder because a full bladder or a fecal impaction is a trigger of autonomic dysreflexia. However, there is another action the nurse should take first.

A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. which of the following is the priority assessment finding? A. Loss of body hair B. Report of anorexia C. Mucositis of the oral cavity D. Erythema at the IV insertion site

D. Erythema at the IV insertion site The greatest risk to the client is injury to the tissue due to extravasation of chemotherapy. Erythema at the IV insertion site can indicate extravasation is occurring, which can lead to infection and tissue loss. This is the priority assessment finding.

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take? A. Assess hourly for a spike in blood pressure B. Keep the client on bed rest C. Keep a padded tongue blade at the bedside D. Establish IV access

D. Establish IV access-The nurse should plan to establish IV access with a large-bore catheter and administer 0.9% sodium chloride if seizures are imminent. If the client is stable, the nurse should initiate a saline lock. Assess hourly for a spike in blood pressure.The nurse should check the client's vital signs and perform neurological checks after a seizure. However, a change in blood pressure does not correlate with an increased incidence of seizure activity. Keep the client on bed rest.A client who is at risk for seizures does not require bed rest. However, if seizures are imminent or frequent, the nurse should institute safety measures, such as placing the mattress on the floor or raising the side rails, according to agency policy. Keep a padded tongue blade at the bedside.MY ANSWERThe nurse should not plan to place objects, such as a padded tongue blade, in the client's mouth during a seizure because it can injure teeth and put the client at risk for aspirating tooth fragments. The tongue blade could also obstruct the client's airway.

A nurse is planning on education program for a group of high school teachers who will be taking students on a hike. Which of the following information should the nurse include regarding Lyme Disease? A. If bitten by a tick, you should be tested immediately. B. Ifyou have a tick embedded in your skin, apply a lit match to remove it C. You should wear dark colored clothing to deter ticks from biting D. If you develop pain and stiffness in your joints, you should see your doctor

D. If you develop pain and stiffness in your joints, you should see your doctor The nurse should inform the group that manifestations of stage 1 Lyme disease include influenza-like manifestations, a "bull's-eye" rash, muscle and joint pain, and stiffness. The nurse should instruct the group to report these findings to a provider.

A nurse is providing dietary teaching for a client who is postoperative following a gastrectomy. Which of the following foods should the nurse encourage the client to include in her diet to prevent dumping syndrome? -Ice cream -Eggs -Grape juice -Honey

Eggs The nurse should instruct the client to increase dietary intake of protein-containing foods, such as eggs, to decrease the risk for manifestations of dumping syndrome. The client should eat some form of protein at each meal.

A nurse is teaching an assistive personnel (AP) about providing care to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? A. Avoid applying antiembolism stockings to the affected leg B. Have the client lean forward when moving from a sitting to a standing position C. Discourage the client from sitting in a wheelchair with the back reclined D. Place an abductor pillow between the client's legs when turning the client

D. Place an abductor pillow between the client's legs when turning the client.- The nurse should inform the AP that a client who had a total hip arthroplasty should maintain the hip in abduction following surgery to reduce the risk of dislocating the affected hip. The AP should place an abductor pillow between the client's legs when turning the client to keep the hips in abduction. Avoid applying antiembolism stockings to the affected leg.-The nurse should instruct the AP that a client who had a total hip arthroplasty should wear antiembolism stockings on both legs postoperatively to prevent the development of emboli in the lower extremities. Have the client lean forward when moving from a sitting to a standing position.-The nurse should instruct the AP that a client who had a total hip arthroplasty should use the unaffected leg and arms to push straight up to standing and not flex the affected hip more than 90°. Discourage the client from sitting in a wheelchair with the back reclined.- The nurse should instruct the AP that a client who had a total hip arthroplasty can sit in either an upright wheelchair or one with a back that reclines to prevent hip flexion greater than 90

A nurse is caring for a client who is recovering from a stroke an has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions? A. Check the client's cheek on the affected side after meals to be sure no food remains there B. Encourage the client to sit upright with their head tilted slightly forward during meals C. Provide the client with eating utensils that have large handles D. Remind the client to look consciously at both sides of their meal tray

D. Remind the client to look consciously at both sides of their meal tray.- Clients who have right-sided homonymous hemianopsia have lost the right visual field of both eyes and might only eat the food they are able to see on the left half of the meal tray. Therefore, the nurse should remind the client to look at both sides of his meal tray to help compensate for the visual loss Check the client's cheek on the affected side after meals to be sure no food remains there.- Homonymous hemianopsia does not cause the client to pocket food. However, food can accumulate on the affected side of the mouth, so the nurse should place food on the unaffected side of the client's mouth when assisting with eating. Encourage the client to sit upright with their head tilted slightly forward during meals.- Homonymous hemianopsia does not cause dysphagia. However, as stroke can cause dysphagia, positioning the client upright and having them tilt their head forward to swallow can help prevent aspiration. Provide the client with eating utensils that have large handles.-Homonymous hemianopsia does not impair the client's fine motor skills. However, as stroke can impair fine motor skills, eating utensils that have a wide grip surface can help compensate for a weak hand grasp.

A nurse is caring for a client who has a pheochromocytoma. Which of the following actions should the nurse take? a. Elevate the head of the client's bed. b. Palpate the client's abdomen. c. Monitor the client for hypotension. d. Check the client's urine specific gravity.

Elevate the head of the client's bed. The nurse should elevate the head of the client's bed to reduce blood pressure and abdominal pressure.

A nurse is planning to teach a client who has epilepsy and a new prescription for phenytoin. Which of the following instructions should the nurse plan to include? A. Rinse with antiseptic mouthwash instead of using dental floss B. Use an OTC antihistamine if a rash develops C. Slowly taper the medication after 6 consecutive months without seizure activity D. Take medications at a consistent time each day to maintain therapeutic blood levels

D. Take medications at a consistent time each day to maintain therapeutic blood levels.- The nurse should teach the client to take antiepileptic medications on a regular schedule to maintain therapeutic blood levels and achieve the maximum effect. Rinse with antiseptic mouthwash instead of using dental floss.The nurse should teach the client that phenytoin can cause gingival hyperplasia, an overgrowth of gum tissue. To minimize gum injury and discomfort, the client should brush and floss after each meal, massage their gums, and schedule dental examinations regularly. Use an over-the-counter antihistamine if a rash develops.The nurse should teach the client to stop taking phenytoin if a rash develops and to report the development of a rash to the provider immediately. An adverse effect of phenytoin therapy is the development of a measles-like rash. If left untreated, the rash could progress to Stevens-Johnson syndrome or toxic epidermal necrolysis. Slowly taper the medication after 6 consecutive months without seizure activity.The nurse should teach the client to continue taking antiepileptic medications even in the absence of seizures. Stopping the medication can lead to the return of seizures or the complication of status epilepticus.

A nurse is planning care for a client who has leukemia and a platelet count of 48,000. Which of the following interventions should the nurse include in the plan? A. Provide the client with a diet that is low in vitamin K B. Place the client on contact precautions C. Administer subcutaneous epoetin alfa D. Test the client's urine and stool for occult blood

D. Test the client's urine and stool for occult blood A client who is thrombocytopenic is at risk for occult bleeding. Therefore, the nurse should test the client's urine and stool for occult blood

A nurse is teaching the parent of a child about administration guidelines for the human papilloma virus vaccine. Which of the following information should the nurse include? A. One dose is administered at birth and another is administered at age 5 B. The vaccine does not protect males C. The vaccine protects against chlamydia D. Three doses are administered to adolescents who start the series after age 15

D. Three doses are administered to adolescents who start the series after age 15 The nurse should inform the parent that the HPV vaccine is recommended for children beginning at age 11 or 12 years. Children who receive the first dose before age 15 should receive two doses of the HPV vaccine. Adolescents who receive the first dose after age 15 should receive three doses of the HPV vaccine.

A nurse is providing discharge teaching for a client following an ileostomy. The nurse should instruct the client to report which of the following findings to the provider? -Intolerance to high-fiber foods -Liquid ileostomy output -Dark purple stoma -Sensation of burning during bowel elimination

Dark purple stoma The nurse should instruct the client to contact the provider if the stoma is a dark purple color, which is an indication of bowel ischemia.

A nurse is assessing a client immediately following a paracentesis for the treatment of ascites. Which of the following findings indicates the procedure was effective? -Presence of a fluid wave -Increased heart rate -Equal pre- and postprocedure weights -Decreased shortness of breath

Decreased shortness of breath MY ANSWER Increased abdominal fluid can limit the expansion of the diaphragm and prevent the client from taking a deep breath. Once excess peritoneal fluid is removed, the diaphragm will expand more freely. The nurse should identify this finding as an indicator the procedure was effective.

A nurse is teaching a client who has diabetes mellitus about insulin injections. The client's prescription includes evening doses of insulin glargine and regular insulin. Which of the following instructions should the nurse include? a. Inject the insulins intramuscularly. b. Shake the insulins vigorously prior to administration. c. Draw up the insulins into separate syringes. d. Expect the insulins to appear cloudy.

Draw up the insulins into separate syringes. The nurse should instruct the client to draw up the insulins into separate syringes because insulin glargine is not compatible with other insulins.

A nurse is admitting a client who has acute pancreatitis. Which of the following actions should the nurse take first? -Insert a nasogastric tube for the client -Administer ceftazidime to the client -Identify the client's current level of pain -Instruct the client to remain NPO

Identify the client's current level of pain. The first action the nurse should take when using the nursing process is to assess the client. Clients who have acute pancreatitis often have severe abdominal pain. By assessing the client's level of pain, the nurse can identify the need for and implement interventions to alleviate the client's pain.

A nurse is providing teaching for a client who has cirrhosis and a new prescription for lactulose. The nurse should include which of the following instructions in the teaching? -Notify the provider if bloating occurs -Expect to have two to three soft stools per day -Restrict carbohydrates in the diet -Limit oral fluid intake to 1,000mL per day of clear liquids

Expect to have two to three soft stools per day. The purpose of administering lactulose is to promote the excretion of ammonia in the stool. The nurse should instruct the client to take the medication every day and inform the client that two to three bowel movements every day is the treatment goal.

A nurse is providing discharge teaching for a client who has a new prescription for medications to treat peptic ulcer disease. The nurse should identify that which of the following medications inhibits gastric acid secretion? -Calcium carbonate -Famotidine -Aluminum hydroxide -Sucralfate

Famotidine The nurse should inform the client that famotidine is an H2-receptor antagonist that is prescribed for the treatment of peptic ulcer disease to inhibit the secretion of gastric acid.

A nurse is monitoring the laboratory values of a client who has diabetes mellitus and is taking insulin. Which of the following results indicates a therapeutic outcome of insulin therapy? a. Fasting blood glucose 96 mg/dL b. Postprandial blood glucose 195 mg/dL c. Random blood glucose 210 mg/dL d. Preprandial blood glucose 60 mg/dL

Fasting blood glucose 96 mg/dL This is within the expected reference range for a fasting blood glucose level and indicates that insulin therapy is effective.

A nurse is assessing a client who has Crohn's disease. Which of the following findings should the nurse expect? -Fatty diarrheal stools -Hyperkalemia -Weight gain -Sharp epigastric pain

Fatty diarrheal stools Steatorrhea, or fatty stool, is an expected finding in a client who has Crohn's disease.

A nurse is caring for a client undergoing screening for primary Cushing's disease. The nurse should expect an elevation in which of the following laboratory findings? a. Lymphocyte count b. Potassium c. Calcium d. Glucose

Glucose Blood glucose is elevated in a client who has Cushing's disease.

A nurse is reviewing the laboratory values of a client who has colorectal cancer. Which of the following findings should the nurse expect? -Negative fecal occult blood test -Decreased serum carcinoembryonic antigen (CEA) level -Hematocrit 43% -Hemoglobin 9.1 g/dL

Hemoglobin 9.1 g/dL A hemoglobin level of 9.1 g/dL is below the expected reference range. Decreased hemoglobin is an expected finding in a client who has colorectal cancer due to occult intestinal bleeding.

A nurse is assessing a client who is postoperative following a gastrectomy. The nurse should identify which of the following findings as an indication of abdominal distention? -Hiccups -Hypertension -Bradycardia -Chest pain

Hiccups Following surgery, hiccups can be caused by irritation of the phrenic nerve due to abdominal distension. If the hiccups are intractable, the nurse should anticipate a prescription for chlorpromazine because persistent hiccups are distressful to the client and can lead to complications, such as vomiting.

A nurse is assessing a client who has a new diagnosis of Cushing's disease. Which of the following findings should the nurse expect? a. Decreased blood pressure b. Weight loss c. Hirsutism d. Increased skin thickness

Hirsutism Increased hair growth, or hirsutism, is an expected finding of Cushing's disease due to increased androgen production.

A nurse is assessing a client who has upper gastrointestinal bleeding. Which of the following findings should the nurse expect? -Bradycardia -Bounding peripheral pulses -Hypotension -Increased hematocrit levels

Hypotension A client who has upper gastrointestinal bleeding is at risk for hemorrhagic shock. Hypotension is a manifestation of hemorrhagic shock

A home health nurse is assessing a client who requires lifelong hormone replacement therapy for the treatment of hypothyroidism. The client has not been taking his medication regularly. Which of the following findings should the nurse expect? a. Increased urine output b. Persistent diarrhea c. Tachycardia d. Hypotension

Hypotension Hypotension is an expected finding with hypothyroidism, along with bradypnea, dysrhythmias, cold intolerance, and cool, dry skin.

A nurse is caring for a client who is taking propylthiouracil. The nurse should identify that the client has met the treatment goals when she reports an increase in which of the following manifestations? a. Increased ability to sweat b. Increased bowel movements c. Increased body weight d. Increased libido

Increased body weight Propylthiouracil suppresses the production of thyroid hormones and, therefore, allows for weight gain. However, excessive weight gain could indicate that the dose of propylthiouracil is too high

A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings? a. Decreased heart rate b. Increased hematocrit c. High urine specific gravity d. Low BUN level

Increased hematocrit An increased hematocrit is an expected finding resulting from dehydration.

A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? -Blood glucose 110 mg/dL -Increased serum amylase -WBC 9,000/mm3 -Decreased bilirubin

Increased serum amylase Serum amylase levels are increased in a client who has acute pancreatitis due to pancreatic cell injury.

A nurse is planning teaching for a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include? a. Consume no more than three servings of alcohol per day. b. Ingest food with alcohol to reduce alcohol-induced hypoglycemia. c. Increase insulin dosage before planned exercise. d. Rest for 3 days between periods of vigorous exercise.

Ingest food with alcohol to reduce alcohol-induced hypoglycemia. Alcohol inhibits the liver from producing glucose. Consuming carbohydrates while drinking alcoholic beverages helps prevent hypoglycemia.

A nurse is assessing a client who has acute hepatitis B. Which of the following findings should the nurse expect? -Joint pain -Obstipation -Abdominal distention -Periumbilical discoloration

Joint pain Joint pain is an expected finding in a client who has acute hepatitis B.

A nurse is monitoring a client's status 24 hours after a total thyroidectomy. Which of the following findings should the nurse report to the provider? a. Laryngeal stridor b. Productive cough c. Pain with hyperextension of the neck d. Hoarse, weak voice

Laryngeal stridor Laryngeal stridor is a harsh, high-pitched sound with inspiration that indicates respiratory obstruction. The nurse should take immediate action to preserve the client's airway.

A nurse is reviewing the prescriptions for a client who has Campylobacter enteritis. Which of the following prescriptions should the nurse clarify with the provider? -0.45% sodium chloride IV -Magnesium hydroxide -Ciprofloxacin -Potassium

Magnesium hydroxide Nausea, vomiting, and diarrhea are manifestations of enteritis. The nurse should clarify a prescription for magnesium hydroxide, also known as milk of magnesia, with the provider. This medication increases gastrointestinal motility, which can increase the client's risk for an electrolyte imbalance and contribute to dehydration.

A nurse is developing a plan of care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan? -Measure the client's abdominal girth -Check mental status once daily -Provide a daily intake of 4g of sodium for the client -Assess the client's breath sounds every 12 hr

Measure the client's abdominal girth daily. The nurse should measure the client's abdominal girth and weigh the client daily to monitor the amount of fluid accumulation in the abdomen and the effectiveness of treatment measures.

A nurse is caring for a client who has diabetes mellitus and has developed peripheral neuropathy. Which of the following measures should the nurse recommend to prevent injuries to the client's feet? a. Examine the skin of the feet feet weekly for alterations in skin integrity. b. Monitor the temperature of bath water with a thermometer. c. Shop for shoes early in the day. d. Round the edges of toenails when trimming them.

Monitor the temperature of bath water with a thermometer. Peripheral neuropathy makes it difficult to determine if bath water is too hot. Therefore, to prevent injury, the client should use a bath thermometer to ensure a water temperature below 43.3° C (110° F).

A nurse has administered propranolol by IV bolus to a client who is having a thyroid storm. Which of the following findings indicates that the client is having a therapeutic response? a. Reduction of the effects of thyroid hormone on the heart b. Blockage of the release of thyroid hormone from the thyroid gland c. Increase in the heart's sensitivity to thyroid hormone d. Increase in the uptake of thyroid hormone by the thyroid gland

Reduction of the effects of thyroid hormone on the heart Propranolol is a beta2-adrenergic blocking agent that decreases the rapid heart rate that excessive thyroid stimulation causes.

A nurse is preparing a teaching plan for a client who has diabetes insipidus and requires intranasal desmopressin. Which of the following information should the nurse include in the teaching plan? a. "Drink at least 3 liters of fluid per day." b. "Weigh yourself weekly while wearing similar clothing at the same time of day." c. "Notify the provider of a weight loss of 1 pound or more per week." d. "Report nocturia because it requires a dosage adjustment."

Report nocturia because it requires a dosage adjustment. The client should receive the initial dose of desmopressin in the evening; the provider will increase the dosage until the client no longer has nocturia.

A nurse is caring for a client who has type 2 diabetes melliltus and has hyperglycemic-hyperosmolar state (HHS). Which of the following laboratory findings should the nurse expect? a. Serum pH 7.32 b. Blood glucose 250 mg/dL c. Blood glucose 425 mg/dL d. Serum pH 7.45

Serum pH of 7.45 A client who has HHS produces enough insulin to prevent ketosis, but not enough to prevent hyperglycemia. Therefore, the serum pH is within the expected reference range. Glucose levels will be above 600 mg/dL.

A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? a. Sodium 110 mEq/L b. 2+ deep-tendon reflexes c. Potassium 3.7 mEq/L d. Urine specific gravity 1.025

Sodium 110 mEq/L A client who has SIADH retains fluids, which causes dilutional hyponatremia.

A nurse is assessing a client who has a duodenal ulcer. Which of the following findings should the nurse expect? -The client states that the pain is in the upper epigastrium. -The client is malnourished. -The client states that ingesting food intensifies the pain. -The client reports that pain occurs during the night.

The client reports that pain occurs during the night. Pain associated with a duodenal ulcer occurs when the stomach is empty, which is typically 1.5 to 3 hr after meals and during the night.

A nurse is caring for a client following a thyroidectomy. The nurse should assess for which of the following findings as an indication of hypocalcemia? a. Strong, bounding pulse b. Decreased bowel sounds c. Tingling and numbness of the hands and feet d. Diminished deep-tendon reflexes

Tingling and numbness of the hands and feet Hypocalcemia causes paresthesias, which usually starts in the hands and feet.

A nurse is admitting a client who has hyperthyroidism. When assessing the client, the nurse should expect which of the following findings? a. Cold intolerance b. Lethargy c. Tremors d. Sunken eyes

Tremors Findings of hyperthyroidism include tremors, diaphoresis, and insomnia.

A nurse is providing discharge teaching for a client who has a new colostomy and is concerned about flatus and odor. Which of the following foods should the nurse recommend to the client? -Eggs -Fish -Yogurt -Broccoli

Yogurt The nurse should recommend yogurt, crackers, and toast, which can prevent flatus and stool odor.

A Nurse is an emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images should the nurse recognize as a comminuted fracture? a. The injury causes the bone to fragment into several pieces. b. Causes the bone to fracture on one side and bend on the other side c. Damage involving the skin or mucous membranes d. Fracture twists around the shaft of the bone

a. Comminuted fracture ---- b = Greenstick fracture c = Open Fracture d = Spiral fracture

A nurse is teaching a client who is postoperative following a right hip arthroplasty. Which of the following images indicated the position the nurse should teach the client to take when sitting in a chair? a. Lady crossing her leg b. Sitting upright c. Sitting with crate under feet d. sitting leaning over a table

b. The nurse should instruct the client to sit with the hips at a 90 degree angle with the knees slightly lower than the hips to avoid hip dislocation. --- a. Client should avoid crossing the affected leg over the center of the body to avoid hip dislocation. c. Client should avoid sitting with the knees higher than the hips to avoid hip dislocation. d. Client should avoid leaning forward over the knees to avoid hip dislocation.

A nurse is reviewing laboratory values for a client who has diabetic ketoacidosis (DKA). Which of the following results should the nurse expect? a. pH 7.32, PaCO2 36 mm Hg, HCO3- 14 mEq/L b. pH 7.38, PaCO2 55 mm Hg, HCO3- 22 mEq/L c. pH 7.44, PaCO2 40 mm Hg, HCO3- 24 mEq/L d. pH 7.50, PaCO2 42 mm Hg, HCO3- 30 mEq/L

pH 7.32, PaCO2 36 mm Hg, HCO3- 14 mEq/L Metabolic acidosis is a common manifestation of DKA, with pH characteristically low, carbon dioxide within the expected reference range, and bicarbonate low.