ATI med surg holy grail

A nurse is teaching a client who has AKI about dietary sources of K. Which of the following statements by the client indicates a need for clarification? "I will enjoy eating cantaloupe for my morning snack." "I can easily add baked potatoes to my diet." "Eating yogurt will be a new experience." "Adding pecans will be a change I can readily make."

"Adding pecans will be a change I can readily make."

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of teaching "If my breathing begins to feel tight, I will use the cromolyn immediately." "I will be sure to take the albuterol before taking the cromolyn." "I will use both medications immediately after exercising." "I will administer the medications 10 minutes apart."

"I will be sure to take the albuterol before taking the cromolyn." The client should always use the bronchodilator (albuterol) prior to using the leukotriene modifier (cromolyn). Using the bronchodilator first allows the airways to be opened, ensuring that the maximum dose of medication will get to the client's lungs. Cromolyn is prophylaxis and not used for acute attacks inhalations can be administered 2-5 minutes apart

A nurse is teaching a client how to do fecal occult blood testing. Which of the following statements by the client indicates a need for further teaching? "I will continue my low-dose aspirin therapy regimen." "I will refrain from eating raw fruits and vegetables." "I will avoid steak and other red meats." "I will continue taking my Coumadin as prescribed."

"I will continue taking my Coumadin as prescribed." The client should discontinue anticoagulants for one week prior to this testing. This statement requires clarification.

A nurse is evaluating teaching on a pt who has a new prescription for montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching "I'll rinse my mouth after taking this medication." "I'll take this medication when I get an asthma attack." "I'll take this medication once a day in the evening." "I'll use a spacer device when I inhale this medication."

"I'll take this medication once a day in the evening." Montelukast, a leukotriene modifier, is used to prevent asthma exacerbations. The client should take it on a daily basis once a day in the evening.

A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching? "A weight loss program can decrease my LDL cholesterol level." "Exercising regularly will increase HDL cholesterol levels." "Adding foods containing omega-3 fatty acids to my diet can lower my risk." "Increasing my intake of foods containing trans-fatty acids can lower my risk."

"Increasing my intake of foods containing trans-fatty acids can lower my risk."

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates that the client is experiencing digoxin toxicity? "I am gaining weight." "I am constipated." "My vision seems yellow." "My tongue is red and beefy."

"My vision seems yellow."

A nurse is preparing a client who has AIDS for discharge. Which of the following statements should the nurse include in the discharge instructions? "Prevent the spread of infection with good household cleaning practices." "Disinfect equipment contaminated with blood or body fluids for twenty-four hours." "Food preparation is not your responsibility." "Burn soiled dressings."

"Prevent the spread of infection with good household cleaning practices." The client should follow standard precautions and use a 1:10 solution of bleach to disinfect areas that come into contact with blood and body fluids.

A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make? "You might want to offer water supplements between feedings." "It is due to the newborn's loss of the influence of the maternal hormones." "This might be related to your baby having 3 stools a day." "The cause might be too short or infrequent feedings."

"The cause might be too short or infrequent feedings." Breastfed newborns typically lose 5% to 6% of body weight before gaining weight. Slow weight gain might be due to inadequate breastfeeding, incorrect feeding techniques, or maternal factors such as breasts not emptying, stress, and fatigue.

A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make? "The laxative will prevent the absorption of magnesium." "The laxative helps eliminate the barium." "The laxative is the protocol at this facility." "The laxative makes the barium turn brown."

"The laxative helps eliminate the barium." The nurse's statement that the laxative will help eliminate the barium is appropriate and provides the client with the reason for the laxative.

A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide? "The primary consideration is what type of incision was performed this time." "There are so many variables that you'll have to ask your obstetrician." "It's too soon for you to be worrying about this now." "A repeat cesarean birth is safer for both you and your baby."

"The primary consideration is what type of incision was performed this time." The most common type of incision during a cesarean birth is transverse, which is made across the lower, thinner part of the uterus. It is the primary criteria that permits a vaginal birth after a cesarean (VBAC). Other types of incisions increase the risk of uterine rupture. Additional criteria for VBAC include an adequate maternal pelvis, no uterine scars or history of rupture, the availability of a provider to monitor labor, and personnel to perform a cesarean birth if needed.

A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer? "You must be feeling scared and powerless." "Everyone worries about her baby when she's in labor." "Your pregnancy is advanced so your baby should be fine." "We have a neonatal unit here that's equipped to handle emergencies."

"You must be feeling scared and powerless." This response illustrates the therapeutic communication technique of restatement. The nurse shows empathy for the client by recognizing that the client is concerned about the safety of the fetus and is powerless to do anything about the situation. This open-ended statement encourages further communication by the client.

A nurse is caring for an adolescent client who has pelvic inflammatory disease as a consequence of a sexually transmitted infection, and will need intravenous antibiotic therapy. The client tells the nurse, "My parents think I am a virgin. I don't think I can tell them I have this kind of an infection." Which of the following responses should the nurse make? "Give your parents a chance; they'll understand." "If you want me to, I can tell your parents for you." "You seem scared to talk to your parents." "Your parents will have to be told why you are being admitted."

"You seem scared to talk to your parents." This is an open-ended therapeutic statement that focuses on the adolescent's concern and allows for further exploration of the client's fear of telling her parents that she is sexually active.

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and SOB. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? -different BP in the upper limbs -Different apical and radial pulses -differences between oral and axillary temperatures -differences in upper and lower lung sounds

-Different apical and radial pulses

A nurse in a cardiac care unit for a client with acute right sided heart failure. Which of the following findings should the nurse expect? -decreased BNP -Elevated CVP -increased PAWP -decreased specific gravity

-Elevated CVP CVP is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure. The BNP is a neurohormone that aids in the regulation of fluid balance by detecting increased stretch of the myocardium and triggering diuresis through sodium excretion via the kidneys. The BNP level is elevated in the client who has acute heart failure. Pulmonary pressure increases in left-sided heart failure because of the increased pressure and volume of blood in the left ventricle. Urinary specific gravity is increased in the client who has heart failure as a result of fluid retention by the body.

A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching? -Reaching your goal BP will occur within 2 months -diuretics are the first type of medication to control HTN -limit for alcohol consumption to 2 drinks a day -plan to lower sat fats to 10% of your daily calorie intake

-diuretics are the first type of medication to control HTN

A nurse is caring for a client with ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? -Pacemaker spikes after each QRS -Pacemaker spikes before each P wave -pacemaker spikes before each QRS complex -Pacemakers Spikes with each T-wave

-pacemaker spikes before each QRS complex

A nurse is creating a dietary plan for an adult female client who has a hemoglobin level of 9.8g/dL. Which of the following foods should the nurse recommend? -carrots -raisins -maple syrup -orange juice

-raisins high in iron

A nurse is caring for a client 1 hr following a subtotal thyroidectomy. In which of the following positions should the nurse place the client? -semi-fowler's -dorsal recumbent -supine -sims'

-semi-fowler's -It is the most comfortable position for a pt who had thyroid surgery. Neck flexion could compromise the airway, and neck extension could place excessive tension on the operative area and the suture. A neutral position is essential.

A nurse is administering platelets to a client who reports having lower back pain and feeling chilled and itchy. Which of the following actions should the nurse take first? -notify the provider -stop the infusion -collect a urine sample from the client -return the platelet bad and tubing to the blood bank

-stop the infusion The greatest risk to this client is injury from a transfusion reaction, which can be more harmful if the client receives more of the blood product. Therefore, the first action the nurse should take is to stop the infusion.

A nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following? Cabbage Cantaloupe Green beans White beans

Cabbage Cabbage should be limited in the diet when taking warfarin, because it is rich in vitamin K.

A nurse is reviewing the laboratory results of a client who was admitted with a history of multiple myeloma. The nurse should expect to find an increase in which of the following laboratory values? Absolute neutrophil count (ANC) Calcium Platelets WBCs

Calcium The nurse expect the calcium level of a client who has a history of multiple myeloma to increase due to the destruction of bone.

A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of gestation. The history includes one pregnancy, terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the GTPAL system, which of the following describes the client's current status? 4-0-1-2-2 3-0-2-0-2 2-0-0-2-0 4-2-0-2-2

4-0-1-2-2 This response correctly describes the client's current status: pregnant currently and had 3 prior pregnancies (G); no term births (T); one pregnancy resulted in the preterm birth (P) of twins; two pregnancies ended in abortion (A); and she has two living children (L).

a nurse is teaching a pt who will undergo a bronchoscopy procedure. The provider will use a rigid scope and general anesthesia. The nurse should explain that the pt's neck will be in which of the following positions A flexed position An extended position A neutral position A hyperextended position

A hyperextended position Hyperextension brings the pharynx into alignment with the trachea and allows insertion of the scope far enough to adequately view airway structures and obtain tissue samples.

A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take? Administer oxygen via nasal cannula. Assist the client to breathe into a paper bag. Have the client tuck her chin to her chest. Instruct the client to increase her respiratory rate to more than 42 breaths per

Assist the client to breathe into a paper bag. This client is experiencing respiratory alkalosis due to hyperventilation. The client should be assisted to breathe into a paper bag or to cup her hands over her mouth to increase the carbon dioxide level, which replaces the bicarbonate ion.

A nurse is caring for a female pt in the ED who reports SOB and pain in the lung area. She states that she started taking BC pills 3 wks ago and she smokes. Her HR is 110, RR 40, BP 140/80. Her ABGs are ph 7.5, PaO2 60, PaCO2 29, HCO3 20, SaO2 86%. Which of the following is a priority nursing intervention? Prepare for mechanical ventilation. Administer oxygen via face mask. Prepare to administer a sedative. Assess for indications of pulmonary embolism.

Administer oxygen via face mask. The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client's oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation.

A nurse is caring for a child who has asthma and a prescription for Montelukast granules. Which of the following instructions should the nurse provide the client's parent on administering the medication Give the medication in the morning daily. Administer the medication 2 hr before exercise. Give the medication at the onset of wheezing. Administer the granules mixed with 20 oz of water.

Administer the medication 2 hr before exercise. Montelukast should be given daily during the evening, except when being used for exercise-induced bronchospasm. It should then be given 2 hr before exercise, and not given again for 24 hr.

A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? A male condom An intrauterine device (IUD) An oral contraceptive A diaphragm with spermicide.

An intrauterine device (IUD) An IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most reliable methods of contraception.

A nurse is developing a plan of care for a client who has a new ileal conduit. The nurse should include that the client is at risk for which of the following? (Select all that apply.) Anxiety Disturbed body image Impaired skin integrity Infection Fluid volume deficit

Anxiety Disturbed body image impaired skin integrity infection Due to the effects an ileal conduit has on lifestyle and relationships, anxiety is appropriate for the nurse to include as a risk. Due to the effects an ileal conduit has on body function, lifestyle, and relationships, disturbed body image is appropriate for the nurse to include as a risk.Due to the external appliance, impaired skin integrity is appropriate for the nurse to include as a risk. Due to the surgical procedure and the potential for obstruction, infection is appropriate for the nurse to include as a risk.

A nurse in the post-anesthesia care unit is caring for a pt who is post op following a thoracotomy and lobectomy. Which of the following post op assessments should the nurse give highest priority to? Arterial blood gases Urinary output Chest tube drainage Pain level

Arterial blood gases According to the ABC priority-setting framework, the postoperative surgical client may need supplemental oxygen in order to maintain normal blood oxygen levels. The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases.

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin infusion at which of the following times? When the client has finished eating lunch When the client states he is ready to start the infusion 2 hr after obtaining blood from the blood bank As soon as the nurse can prepare the client and the administration set

As soon as the nurse can prepare the client and the administration set The nurse should infuse the blood as soon as possible and complete the procedure within 4 hr.The nurse should begin the infusion as soon as possible after obtaining the packed RBCs from the blood bank.

A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure? Observe color and consistency of fluid. Assess the fetal heart rate pattern. Assess the client's temperature. Evaluate client for the presence of chills and increased uterine tenderness using palpation.

Assess the fetal heart rate pattern. Variable fetal heart rate decelerations and bradycardia can occur with an amniotomy as a result of umbilical cord prolapse or compression. Cord prolapse necessitates an emergent delivery.

A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take? Insert a nasogastric tube. Administer an antiemetic. Encourage use of the incentive spirometer. Auscultate bowel sounds.

Auscultate bowel sounds. MY ANSWER Using the nursing process, assessing for the presence or absence of bowel sounds and the passage of flatus is an appropriate action at this time. Determining the cause of the nausea and reducing contributing factors should precede any treatment.

A nurse is providing teaching to a pt who has emphysema and a new prescription for theophylline. Which of the following instructions should the nurse provide? Consume a high-protein diet. Administer the medication with food. Avoid caffeine while taking this medication. Increase fluids to 1L/per day.

Avoid caffeine while taking this medication. The nurse should instruct the client that caffeine should be avoided while taking theophylline, as it can increase central nervous system stimulation.

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching? Eat plenty of fresh fruits and vegetables. Avoid crowds. Perform mild exercise, such as gardening. Take temperature weekly.

Avoid crowds. The nurse should inform the client to avoid crowds due to his suppressed immune system.

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

Avoid foods high in fat. The nurse should instruct the client to follow a low-fat diet to decrease episodes of biliary colic. A client who has chronic cholecystitis has intolerance to fatty foods.

A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first? Observe for cerebrospinal fluid (CSF) leaks from the evacuation site. Assess for an increase in temperature. Check the oximeter. Monitor for manifestations for increased intracranial pressure.

Check the oximeter. The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to maintain a patent airway. Checking the oximeter is the first indicator of poor oxygen exchange which can cause cerebral edema.

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

Chocolate The client should avoid foods that reduce pressure on the lower esophageal sphincter. These include fatty and fried foods, chocolate, caffeine, alcohol, and carbonated drinks.

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn? Clear the respiratory tract. Dry the infant off and cover the head. Stimulate the infant to cry.

Clear the respiratory tract. Clearing the airway of the infant is the first action the nurse should take immediately following delivery.

A nurse is assessing for cyanosis in a pt who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? Pinnae of the ears Dorsal surface of the hand Conjunctivae Dorsal surface of the foot

Conjunctivae To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, conjunctivae, and mucous membranes.

A nurse is caring for a client who is 12 hr post op and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? Constant bubbling in the suction-control chamber Continuous bubbling in the water-seal chamber Bloody drainage in the collection chamber Fluid-level fluctuations in the water-seal chamber

Continuous bubbling in the water-seal chamber Continuous or excessive bubbling in the water-seal chamber indicates an air leak between the water seal and the client's chest. However, gentle bubbling on forceful exhalation or coughing is normal.

A nurse is teaching a client who is post-op following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? SATA Count your pulse for 1 min each morning. Resume activities that can cause jolting, such as horseback riding, after 4 weeks. Do not wear tight clothing over the insertion area. Request to be scanned with a handheld metal detector when in the airport. Do not have a microwave oven in the home.

Count your pulse for 1 min each morning. Do not wear tight clothing over the insertion area.

A nurse is preparing a client for a radiation treatment who is postoperative following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the treatment? Alopecia Diarrhea Fatigue Anorexia

Fatigue The nurse should inform the client to expect fatigue with her radiation treatment. Fatigue occurs regardless of the radiation target site.

A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors? Pale yellow Greenish-brown Red Dark and foamy

Dark and foamy The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are filtering excess bilirubin from the blood.

A nurse is providing discharge instructions to a pt who has asthma and a new prescriptions for montelukast. The nurse should instruct the pt to report which of the following adverse effects to the provider Blurred vision Palpitations Constipation Depression

Depression Montelukast can cause neuropsychiatric effects such as depression, behavior changes, hallucinations, and suicide ideation. The nurse should instruct the client to report such adverse effects. A change in medication might be prescribed.

A nurse is caring for a client 8hr post op following a total knee replacement. Which of the following actions should the nurse take? Place a pillow under the affected limb. Apply cool compresses to the affected limb every 6 hr. Promote bed rest for 5-7 days. Encourage increased fluid intake.

Encourage increased fluid intake.

A nurse is caring for a pt who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? Encourage the client to ambulate frequently. Encourage coughing and deep breathing. Encourage the client to increase fluid intake. Encourage regular use of the incentive spirometer.

Encourage the client to increase fluid intake. Increasing fluid intake to1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client? Rapid decline in human chorionic gonadotropin (hCG) levels Profuse, clear vaginal discharge Irregular fetal heart rate Excessive uterine enlargement

Excessive uterine enlargement A hydatidiform mole is a rare tumor that forms inside the uterus at the beginning of a pregnancy and results in the over-production of tissue that would normally develop into the placenta. This tissue consists of fluid-filled vesicles. A rapidly enlarging uterus is a classic finding in clients who have a molar pregnancy. It is often accompanied by severe nausea and vomiting, elevated human chorionic gonadotropin levels, signs of hyperthyroidism, and early onset of preeclampsia.

A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations? Leukorrhea Urinary frequency Nausea and vomiting Facial edema

Facial edema Facial edema is a warning sign of a hypertensive condition or preeclampsia and should be reported immediately to the provider.

A nurse in a prenatal clinic is caring for a client who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. Which of the following is the appropriate response by the nurse? February 11, 2016 February 27, 2016 April 27, 2016 April 11, 2016

February 11, 2016 Subtracting 3 calendar months and adding 7 days plus one year will result in this estimated date of delivery.

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify? Fetal attitude is in general flexion. Fetal lie is longitudinal. Maternal pelvis is gynecoid. Fetal position is persistent occiput posterior.

Fetal position is persistent occiput posterior. The persistent occiput posterior position of the fetus is a common cause of prolonged, difficult labor with severe back pain as spinal nerves are being compressed. Counterpressure or a hands-and-knees position can offer pain relief.

A nurse is providing discharge instructions to a client who developed DVT post op and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? Applying cool compresses to her legs Wearing loose, non-constricting stockings Flexing her knees and feet frequently Taking an NSAID tablet daily

Flexing her knees and feet frequently

A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following? Graham crackers 1 tsp sugar 4 oz diet soda 4 oz skim milk

Graham crackers After establishing that the client has hypoglycemia, the nurse should give the client about 15 g of a rapid-acting, concentrated carbohydrate, such as 4 oz of fruit juice, 8 oz of skim milk, 3 tsp of sugar or honey, 3 graham crackers, or commercially prepared glucose tablets. The nurse should recheck the client's blood glucose level in 15 minutes.

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption? Cocaine use Hypertension Blunt force trauma Cigarette smoking

Hypertension Maternal hypertension, either chronic or related to pregnancy, is the most common risk factor for placental abruption.

A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching? "I will eat smaller meals if I feel nauseated." "I will eat foods that are served at room temperature." "I will drink more liquids with my meals." "I will increase the amount of unsaturated fats in my diet."

I will eat foods that are served at room temperature." The nurse should instruct the client to eat foods served at room temperature or chilled. Foods served hot may contribute to nausea.

A nurse is monitoring a client following a thoracentesis. The nurses should identify which of the following manifestations as a complication and contact the provider immediately Serosanguineous drainage from the puncture site Discomfort at the puncture site Increased heart rate Decreased temperature

Increased heart rate Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require notification of the provider immediately.

A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make? Retained bile in the liver results in delayed digestion. Increased estrogen production causes increased secretion of hydrochloric acid. Pressure from the growing uterus displaces the stomach. Increased progesterone production causes decreased motility of smooth muscle.

Increased progesterone production causes decreased motility of smooth muscle. Increased progesterone production causes a relaxation of the cardiac sphincter of the stomach and delayed gastric emptying, which can result in heartburn.

A nurse is providing preoperative teaching by demonstration diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration? Place her hands on the sides of her rib cage. Inhale slowly and evenly through her nose. Hold her breath for at least 10 seconds. Exhale forcefully through the nose.

Inhale slowly and evenly through her nose. The nurse should inhale slowly and evenly through her nose until chest expansion is maximized. palms should be placed on border of rib cage, hold breath for 2-3 seconds and exhale slowly through the mouth

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first? Cover the cord with a sterile, moist saline dressing. Prepare the client for an immediate birth. Place the client in knee-chest position. Insert a gloved hand into the vagina to relieve pressure on the cord.

Insert a gloved hand into the vagina to relieve pressure on the cord. This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation of the fetus.

A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho (D) immunoglobulin. Which of the following should be included in the teaching? It prevents the formation of Rh antibodies in mothers who are Rh negative. It destroys Rh antibodies in mothers who are Rh negative. It destroys Rh antibodies in newborns who are Rh positive. It prevents the formation of Rh antibodies in newborns who are Rh positive.

It prevents the formation of Rh antibodies in mothers who are Rh negative. Rho (D) immunoglobulin prevents the immune system of a client who is Rh negative from reacting to accidental exposure to fetal blood during pregnancy or delivery. If the client has another Rh positive fetus in the future, these antibodies can destroy the blood cells of the fetus. Rho (D) immunoglobulin is administered routinely to Rh negative mothers at 28 weeks of gestation and following any pregnancy outcome (including birth or any planned or unintentional fetal loss).

A nurse is caring for a pt who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take Clamp the tube when the client is ambulating. Keep the collection device below the level of the client's chest. Coil the tubes carefully to prevent kinking. Lay the client flat to avoid leaks in the tubing.

Keep the collection device below the level of the client's chest. The nurse should keep the drainage system lower than the client's chest to facilitate drainage from the chest cavity.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following? Fetal lung maturity Location of the placenta Viability of the fetus The biparietal diameter

Location of the placenta Painless, spontaneous vaginal bleeding might indicate that the client has placenta previa. Placenta previa is a condition in which the placenta is implanted low in the uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. The ultrasound will show the location of the placenta and help to determine what sort of delivery the client requires and how emergent it is.

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain? Lower left quadrant Upper left quadrant Lower right quadrant Upper right quadrant

Lower left quadrant The nurse should expect the client to have abdominal pain in the lower left quadrant of the abdomen. The disease is usually found in the sigmoid colon, where high pressure to move fecal contents from the rectum causes pouch formation.

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? Serum cardiac enzyme levels MRI of the chest Physical therapy Low-sodium diet

MRI of the chest A permanent pacemaker is a contraindication for MRI of the chest. The magnets in the machine can create electromagnetic interference and cause the pacemaker to malfunction.

A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include? A family history increases your risk for acquiring hepatitis A. Hepatitis A infects the kidneys. Manifestations of the virus are similar to flu-like symptoms. The incubation of the virus is 5 days.

Manifestations of the virus are similar to flu-like symptoms. The nurse should include in the teaching that the manifestations of hepatitis A are similar to having the flu or a gastrointestinal illness. Often the client is unaware that they have acquired the virus.

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain? Administer prescribed analgesic medication. Encourage the client to rest between contractions. Massage the client's back. Turn the client onto her left side.

Massage the client's back. The gate control theory of pain is based on the concept of blocking or preventing the transmission of pain signals to the brain by using distraction techniques such as massage. Massaging the client's back focuses on neuromuscular and cognitive changes.

A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority? Give the client 15 to 20 g of carbohydrate. Monitor the client for hypoglycemia. Complete an incident report. Notify the nurse manager.

Monitor the client for hypoglycemia. The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should immediately check the client's blood glucose level, expecting it to be low because of the excessive dose of insulin. If it is within the expected reference range, the nurse should continue to monitor the client for signs of hypoglycemia.

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion? Sudden lethargy. Muffled heart sounds. Flattened neck veins. Bradycardia.

Muffled heart sounds.

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis? Hyperactive bowel sounds Nausea and vomiting Bradycardia Increased urinary output

Nausea and vomiting Peritonitis is an inflammation of the peritoneum and is a potential complication of peritoneal dialysis. The nurse should monitor the client for manifestations such as abdominal tenderness or pain, anorexia, nausea, vomiting, restlessness, and confusion.

The nurse is admitting a client who has acute HF following MI. The nurse recognizes that which of the following prescriptions by the provider requires clarification? Morphine sulfate 2 mg IV bolus every 2 hr PRN pain Laboratory testing of serum potassium upon admission 0.9% normal saline IV at 50 mL/hr continuous Bumetanide 1 mg IV bolus every 12 hr

Normal saline IV at 50ml/hr continuous Rationale: 0.9% sodium chloride is isotonic and will not cause the fluid shift need in this client to reduce circulatory overload. This prescription requires clarification

A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client? Good Guarded Poor Very good

Poor At this advanced stage, the prognosis for ovarian cancer is poor. Ovarian cancer is the leading cause of death from female reproductive cancers. Survival rates are low because it is not often discovered until its late stages.

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take? Notify the provider of the findings. Position the client with one hip elevated. Ask the client if she needs pain medication. Have the client void.

Position the client with one hip elevated. Based on Maslow's hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess.

A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client? Unilateral swelling on the posterior of the vulva Extreme abdominal pain with intercourse Green, malodorous vaginal discharge Postmenopausal bleeding

Postmenopausal bleeding Endometrial cancer involves cancerous growth of the endometrium (lining of the uterus). The most common manifestation of endometrial cancer is abnormal uterine bleeding, including postmenopausal bleeding and bleeding between normal periods in premenopausal women.

A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan? Oranges Cashews Red meat Yogurt

Red meat Red meat is a good source of iron. If the client is vegetarian, kidney beans with a high iron content are a good substitute.

A nurse is caring for an antepartum client who has iron-deficiency anemia. When teaching the client about nutrition, the nurse should emphasize the need for an increased intake of which of the following foods? Milk and cheese Red meat and organ meat Fresh fruits Whole grain breads

Red meat and organ meat This client has a deficiency in iron and needs instruction about foods that are rich sources of iron. A diet rich in red and organ meat provides iron, which is what the client needs to improve anemia.

As part of an annual physical, a nurse is preparing a pt to undergo a chest xray. Which of the following instructions should the nurse give the pt prior to the procedure? Remove all metal necklaces. Take several shallow breaths during the procedure. Do not eat or drink anything the morning of the test. Expect minor discomfort after the procedure.

Remove all metal necklaces. Metal objects block visualization of body structures and tissues, thus the client must remove them.

A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority? Respiratory rate Burns of the mouth Bowel sounds Visual acuity

Respiratory rate Using the airway, breathing, circulation approach to client care, the nurse should prioritize assessing the client's respiratory rate. Small amounts of kerosene can enter the lungs and damage them directly, causing a severe aspiration pneumonia. Because the pneumonia is caused by chemical irritation rather than bacteria, antibiotics aren't useful for prevention or treatment. Breathing becomes rapid and gasping, and vomiting and persistent coughing can follow. In severe cases, brain damage can occur.

A nurse is caring for a male client who has peripheral vascular disease, is taking dietary supplements, and has a new prescription for warfarin. The nurse should instruct the cline tot stop which of the following supplements prior to taking the warfarin? (SATA) -Saw palmetto -flaxseed oil -glucosamine -black cohosh -gingko biloba

Saw Palmetto Glucosamine Gingko bilboa

A nurse is teaching a pt about taking diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect to this medications Sedation Constipation Hypertension Bradycardia.

Sedation Diphenhydramine can cause sedation. It is used to treat rhinitis, allergies, and insomnia.

A nurse at the EOD is caring for a client who sustained a head injury. The nurse notes the clients IV fluids are infusing at 125mL/hr. Which of the following is an appropriate action by the nurse? Slow the rate to 20 mL/hr. Continue the rate at 125 mL/hr. Slow the rate to 50 mL/hr. Increase the rate to 250 mL/hr.

Slow the rate to 50 mL/hr.

A nurse is teaching a pt about taking an expectorant to treat a cough. The nurse should explain that this type of medication has which of the following actions Reduces inflammation Suppresses the urge to cough Dries mucous membranes Stimulates secretions

Stimulates secretions Expectorants act by increasing secretions to improve a cough's productivity.

A nurse is preforming tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take Suction two to three times with a 60-second pause between passes. Perform chest physiotherapy prior to suctioning. Lubricate the suction catheter tip with sterile saline. Hyperventilate the client on 100% oxygen prior to suctioning.

Suction two to three times with a 60-second pause between passes. Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia. lubrication and hyperventilation have no effect on the removal of secretions and thats why theyre wrong apparently

A nurse is providing discharge instructions to a pt who has asthma and is about the start taking theophylline. The nurse should tell the pt that this medication might cause which of the following adverse effects? Drowsiness Constipation Oliguria Tachycardia

Tachycardia Theophylline can increase cardiac stimulation and cause tachycardia.

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion? Skin color Fluid intake Temperature Hemoglobin level

Temperature

A nurse is teaching a client who has asthma about how to use an albuterol inhaler which on the following actions by the client indicates an understanding of the teaching The client holds his breath for 10 seconds after inhaling the medication. The client takes a quick inhalation while releasing the medication from the inhaler. The client exhales as the medication is released from the inhaler. The client waits 10 min between inhalations.

The client holds his breath for 10 seconds after inhaling the medication. The medication should be retained in the lungs for a minimum of 10 seconds so the maximum amount of the dosage can be delivered properly to the airways. To use the inhaler, the client exhales normally just prior to releasing the medication, inhales deeply as the medication is released, then holds the medication in the lungs for approximately 10 seconds prior to exhaling.

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? The client is not experiencing a rubella infection at this time. The client is immune to the rubella virus. The client requires a rubella vaccination at this time. The client requires a rubella immunization following delivery.

The client requires a rubella immunization following delivery. A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month.

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include? -The client cannot travel by air due to security screening -The client should hold his cell phone on the side opposite the icd -the client should avoid the use of small electric devices -the client should avoid the use of small electric devices -The client can carry his ICD in a small pocket

The client should hold his cell phone on the side opposite the icd Close proximity could interfere w/ the ICD's function

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following? Uteroplacental insufficiency Maternal bradycardia Umbilical cord compression Fetal head compression

Uteroplacental insufficiency The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late decelerations are the result of uteroplacental insufficiency and the fetus becomes hypoxemic. They are an ominous sign if they cannot be corrected and place the fetus at risk for a low Apgar score.

A nurse is caring for a pt who is 1 day post op following a left lower lobectomy and has a chest tube. When assessing the pt's 3 chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? Continue to monitor the client as this is an expected finding. Add more water to the suction control chamber of the drainage system. Verify that the suction regulator is on and check the tubing for leaks. Milk the chest tube and dislodge any clots in the tubing that are occluding it.

Verify that the suction regulator is on and check the tubing for leaks. A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing.

A nurse is preparing the administer blood to a client. Which of the following actions should the nurse take to identify the client? SATA Verify the provider's prescription with another RN. Confirm that the room number matches the medical record. Scan the barcode on the client's identification band. Ask the client to verbalize if blood type is Rh-negative or positive. Compare client identification number to the blood component tag number.

Verify the provider's prescription with another RN. Scan the barcode on the client's identification band. Compare client identification number to the blood component tag number.

A nurse is teaching a client who has a vitamin K deficiency about the effects of vitamin K. Which of the following information should the nurse include in the teaching? Vitamin K reverses warfarin toxicity. Vitamin K promotes fibrinogen formation. Vitamin K is produced in the gastric juices. Vitamin K is produced in the liver.

Vitamin K reverses warfarin toxicity Vitamin K promotes prothrombin formation in the liver. It normalizes the clotting factors reflected in PT, not in aPTT.

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the pt to report? Sedation Increased appetite White coating in the mouth Dry oral mucous membranes

White coating in the mouth Fluticasone/salmeterol is an inhaled glucocorticoid and long acting beta2 adrenergic agonist combination inhalation medication that is used for daily management of asthma. It is not a rescue medication. An adverse effect of the medication is oropharyngeal candidiasis. The nurse should instruct the client to gargle after each use, use a spacer to reduce the amount of drug in the mouth and throat, and report any white patches inside the mouth or on the tongue to the provider.

A nurse is assisting a client who has hypothyroidism with meal planning. Which of the following foods should the nurse recommend that the client add to her diet? Ripe bananas Poached eggs Whole grains Baked chicken

Whole grains Constipation is a classic manifestation of hypothyroidism; therefore, this client should increase her fluid and fiber intake. Whole grains provide ample amounts of fiber.

A nurse is caring for a pt who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate? Withhold food and liquids until the client's gag reflex returns. Irrigate the client's throat every 4 hr. Have the client refrain from talking for 24 hr. Suction the client's oropharynx frequently.

Withhold food and liquids until the client's gag reflex returns. Until the gag reflex returns, and the sedation effects have resolved, the client is at high risk for aspirating food or fluids. Also, oxygen saturation should be checked every 15 min. for 2 hr.

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention? Auscultate the client's lungs. Assist the client to a side-lying position. Provide oral hygiene. Withhold oral fluids and food.

Withhold oral fluids and food. To rest the pancreas and reduce secretion of pancreatic enzymes, NPO status must be initiated and maintained during the acute phase of pancreatitis. This is the priority intervention to address after the client's pain has been treated.

A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.) Loss of color discrimination. Coarse facial features Enlarged distal extremities Hepatomegaly

loss of color discrimination Acromegaly is a chronic metabolic disorder caused by an excess of growth hormone (hyperpituitarism) during adulthood, after normal growth of the skeleton and other organs is complete. Often rising from an adenoma, the tumor compresses the optic nerve and causes visual changes such as loss of color discrimination, narrowed perceptual field, or blindness.

A nurse is caring for a client during a nonstress test (NST). At the end of a 30-min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15 /min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make? A negative test A nonreactive test A positive test A reactive test

nonreactive test An NST that does not produce two or more qualifying accelerations within a 20-min period is interpreted as nonreactive. Qualifying accelerations peak at least 15 /min above the FHR baseline and last at least 15 seconds.

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions? ​Apply hydrating lotions. ​Apply moist heat. Sit in the sun for 10 min per day. ​Wash with plain soap and water.

​Apply hydrating lotions. The nurse should instruct the client to gently apply hydrating lotions that do not contain metal, alcohol, or perfume.