ATI MEDICAL SURGICAL 2
A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hr. A blood administration set is available that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)
10 gtt/mL x 250 mL = 2,500 gtt 2,500 gtt / 4 hours = 625 625 / 60 min = 10.41 = 10 gtt per min
A nurse is assessing a client who is 1 week postoperative following a living donor kidney transplant. Which of the following findings indicates the client is experiencing acute kidney rejection? A. Blood pressure 160/90 mmHg B. Creatinine 0.8 mg/dL C. Sodium 137 mg/dL D. Urinary output 100 mL/hr
A. Blood pressure 160/90 mmHg
A nurse is performing discharge teaching about ostomy care while at home for a client who has a newly placed ileostomy. Which of the following instructions should the nurse include in the teaching? A. "Empty your ostomy pouch when it becomes half full." B. "Place an aspirin in the ostomy pouch to eliminate odor." C. "Change the ostomy appliance every week." D. "Cleanse the site around the stoma with hydrogen peroxide and water."
A. "Empty your ostomy pouch when it becomes half full."
A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to take methotrexate, even if I'm in remission." B. "I'm thankful that this type of lupus only affects the skin." C. "Each day, I should apply a sunblock with a sun protection factor of 15." D. "A mild fever is common with SLE and usually does not require medical intervention."
A. "I will need to take methotrexate, even if I'm in remission."
A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching? A. "Wash your genitalia using an antimicrobial soap." B. "Rinse your dishes with cold water." C. "Clean your toothbrush once per month." D. "Incorporate raw fruits and vegetables into your diet."
A. "Wash your genitalia using an antimicrobial soap."
A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi
A. Absence of breath sounds
A nurse is assisting a provider with performing a paracentesis on a client. Which of the following actions should the nurse take? A. Ask the client to empty his bladder before the procedure B. Place the client leaning forward over the bedside table for the procedure C. Inform the client he will be sedated during the procedure D. Instruct the client to fast for 6 hr prior to the procedure
A. Ask the client to empty his bladder before the procedure
A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications? A. Aspiration of water B. Infection of the stoma C. Bleeding around the stoma D. Skin breakdown around the stoma
A. Aspiration of water
A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? (Select all that apply.) A. Assess and document the client's vital signs B. Restart the IV with a 22-gauge needle C. Verify with another nurse the blood type and Rh of the packed RBCs D. Hang a bag of lactated Ringer's IV solution E. Change IV tubing to a set that has a filter
A. Assess and document the client's vital signs C. Verify with another nurse the blood type and Rh of the packed RBCs E. Change IV tubing to a set that has a filter
A nurse is caring for a client who is postoperative following a parathyroidectomy to treat hyperparathyroidism. Which of the following laboratory values should the nurse expect to decrease as a therapeutic effect of the procedure? A. Calcium B. Sodium C. Potassium D. Phosphorous
A. Calcium
A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? A. Children B. Older adults C. Women who are pregnant D. Middle-aged men
A. Children
A nurse is caring for a client who is 3 days postoperative following abdominal surgery. The client states, "Something just popped when I coughed." Which of the following actions should the nurse take first? A. Cover the client's wound with a sterile, moist dressing B. Flex the client's knees C. Reassure the client D. Instruct the client to avoid coughing
A. Cover the client's wound with a sterile, moist dressing
A nurse is teaching a client who has a colostomy about ways to reduce flatus and odor. Which of the following strategies should the nurse include? A. Eat crackers and yogurt regularly B. Chew minty gum throughout the day C. Drink orange juice every day D. Put an aspirin in the pouch
A. Eat crackers and yogurt regularly
nurse is caring for a client who has osteoporosis and a new prescription for calcium supplements. Which of the following foods should the nurse recommend to promote calcium absorption? A. Fortified milk B. Ripe bananas C. Steamed broccoli D. Green leafy vegetables
A. Fortified milk
A nurse is assessing a client who has Addison's disease. Which of the following findings should the nurse expect? A. Hypotension B. Weight gain C. Sugar craving D. Pale skin tone
A. Hypotension
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Jugular vein distension B. Moist crackles C. Postural hypotension D. Increased heart rate E. Fever
A. Jugular vein distension B. Moist crackles D. Increased heart rate
A nurse is teaching a client with chronic kidney disease about predialysis dietary recommendations. The nurse should recommending restricting the intake of which of the following nutrients? A. Protein B. Carbohydrates C. Calcium D. Monounsaturated fats
A. Protein
A nurse is caring for a client who has a diagnosis of renal calculi and reports severe flank pain. Which of the following is the priority nursing action? A. Relieve the client's pain B. Encourage the client to increase fluid intake C. Monitor the client's intake and output (I&O) D. Strain the client's urine
A. Relieve the client's pain
A nurse is caring for a client who had a thyroidectomy to treat hyperthyroidism caused by an adenoma. Which of the following findings should the nurse report to the provider? (Select all that apply.) A. Tachycardia and hypertension B. Respiratory rate 16/min C. Negative Chvostek's sign D. Laryngeal stridor and hoarseness E. Positive Trousseau's sign
A. Tachycardia and hypertension D. Laryngeal stridor and hoarseness E. Positive Trousseau's sign
A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? A. The client rigidly extends his arms. B. The client internally flexes his wrists. C. The client curls into a fetal position. D. The client internally rotates his legs.
A. The client rigidly extends his arms.
A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates that the medication is having a therapeutic effect? A. The client's serum osmolarity is 310 mOsm/L. B. The client's pupils are dilated. C. The client's heart rate is 56/min. D. The client is restless.
A. The client's serum osmolarity is 310 mOsm/L.
A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? A. Turn the client from side to side B. Elevate the height of the dialysate bag C. Lower the head of the client's bed D. Advance the catheter approximately 2.5 cm (1 in) further
A. Turn the client from side to side
A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching? A. "A hepatitis B immunization is recommended for those who travel, especially military personnel." B. "A hepatitis B immunization is given to infants and children." C. "Hepatitis B is acquired by eating foods that are contaminated during handling." D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."
B. "A hepatitis B immunization is given to infants and children."
A nurse is providing discharge teaching to the partner of a client who has acquired immune deficiency syndrome (AIDS). Which of the following statements by the client's partner indicates a need for further teaching? A. "I will dispose of soiled tissues in separate plastic bags." B. "I'll clean up blood spills immediately with hot water." C. "I know that handwashing is an important preventive measure." D. "I will wash soiled clothes in hot water."
B. "I'll clean up blood spills immediately with hot water."
A nurse is providing post-procedural teaching to a client who had a diagnostic knee arthroscopy. Which of the following statements indicates that the client understands the nurse's instructions? A. "I'll take aspirin to relieve my pain." B. "I'll keep my leg elevated for the first day." C. "I'll put a heating pad on my knee for the first day." D. "I'll resume my usual activities as soon as I leave."
B. "I'll keep my leg elevated for the first day."
A nurse is performing an admission assessment for a client who has colorectal cancer. Which of the following manifestations should the nurse expect to find? A. Hematuria B. Abdominal cramps C. Weight gain D. Polycythemia
B. Abdominal cramps
A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, which of the following responses should the nurse provide? A. "You need to conserve energy at this time." B. "Lying quietly in bed helps slow down the activity in your intestines." C. "Staying in bed promotes the rest and comfort you need." D. "Staying in bed will help prevent injury and minimize your fall risk."
B. "Lying quietly in bed helps slow down the activity in your intestines."
A nurse is providing discharge teaching to a client who has emphysema. Which of the following instructions should the nurse include? A. "Be sure to take cough medicine to avoid coughing." B. "Try to drink at least 2 to 3 liters of fluid per day." C. "Try to reduce your smoking to 2 cigarettes per day." D. "Be sure to eat 3 full meals each day."
B. "Try to drink at least 2 to 3 liters of fluid per day."
A nurse is providing teaching about exercise to a client who has type 1 diabetes mellitus. Which of the following statements should the nurse include? A. "You should exercise during a peak insulin time." B. "Wear a medical alert identification tag when you exercise." C. "Exercise can decrease the effects of insulin and cause your blood glucose levels to increase." D. "You will get the most benefit from exercise when your glucose levels are higher than normal."
B. "Wear a medical alert identification tag when you exercise."
A nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine cancer. Which of the following pieces of information should the nurse include in the teaching? A. "You will need to continue to use some form of birth control for 6 months." B. "You might experience manifestations of menopause." C. "Do not lift anything heavier than 15 lb." D. "Pain or burning with urination is an expected outcome of this surgery."
B. "You might experience manifestations of menopause."
A nurse is presenting an in-service training session about nutrition. How many of the amino acids must be obtained from dietary intake? A. 6 B. 9 C. 11 D. 15
B. 9
A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? A. Eliminating environmental triggers that precipitate attacks B. Addressing the client's perception of the disease process and what might have triggered past attacks C. Overviewing the client's medication regimen D. Explaining manifestations of respiratory infections
B. Addressing the client's perception of the disease process and what might have triggered past attacks
A nurse is providing teaching to a client who has constipation. Which of the following instructions should the nurse include? A. Use bismuth subsalicylate regularly B. Consume a low-fiber diet C. Eat yogurt with live cultures D. Use bisacodyl suppositories regularly
B. Consume a low-fiber diet
A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect? A. Reduced left-sided motor function B. Difficulty with speech C. Impulsive behavior D. Neglect of the left side of the body
B. Difficulty with speech
A nurse is planning care for a client who is postoperative following a gastrectomy. Which of the following strategies should the nurse include to help prevent dumping syndrome? A. Have the client drink plenty of water with meals B. Eliminate simple sugars and sugar alcohols from the client's diet C. Limit the client's intake to 2 meals per day D. Offer the client meals that are low in protein or protein-free
B. Eliminate simple sugars and sugar alcohols from the client's diet
A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures of his tibia, ulna, and several ribs. The client is now disoriented to time and place and has a SaO2 of 87%. The nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? A. Hypovolemic shock B. Fat embolism syndrome C. Thrombophlebitis D. Avascular bone necrosis
B. Fat embolism syndrome
A nurse is caring for a client who is in skeletal traction following a femur fracture. On entering, the nurse finds that the client has slid toward the foot of the bed, and the traction weight is resting on the floor. Which of the following actions should the nurse take? A. Remove the weight temporarily to reposition the client to the correct alignment in bed B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely C. Lift the rope off the pulley while the client rocks back and forth to reposition himself D. Lift the weight manually while another staff member moves the client up in bed
B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely
A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (Select all that apply.) A. Hypothyroidism B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking
B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking
A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses by the nurse is appropriate? A. Basal cell carcinoma B. Melanoma C. Actinic keratosis D. Squamous cell carcinoma
B. Melanoma
A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? A. Pupils nonreactive to light B. Opacity visible behind the pupil C. White circle around the outside border of the iris D. Increased intraocular pressure
B. Opacity visible behind the pupil
A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? A. Tympanic temperature 38°C (100.4°F) B. PaO2 50 mmHg C. Rhonchi D. Hypopnea
B. PaO2 50 mmHg
A nurse is assessing a client who is receiving continuous ambulatory peritoneal dialysis. Which of the following findings should the nurse report to the provider? A. WBC 6,000/mm^3 B. Potassium 3.0 mEq/L C. Clear, pale yellow drainage D. Report of abdominal fullness
B. Potassium 3.0 mEq/L
A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a "flash" of light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders? A. Glaucoma B. Retinal detachment C. Macular degeneration D. Cataracts
B. Retinal detachment
A nurse is evaluating the injection site of a client who had a Mantoux skin test 48 hr ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make? A. The client has active tuberculosis. B. The client had an exposure to tuberculosis. C. The nurse must re-evaluate the result in 24 hr. D. The test is negative for tuberculosis.
B. The client had an exposure to tuberculosis.
A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The client asks the nurse about the usual cause of MS. Which of the following responses should the nurse make? A. "Each client is different; we cannot predict what will happen." B. "I can see that you are worried, but it's too soon to predict what will happen." C. "Acute episodes are usually followed by remissions, which can vary in duration." D. "It's too early to think about the future; let's focus on the present and take each day as it comes."
C. "Acute episodes are usually followed by remissions, which can vary in duration."
A nurse is caring for a client who is postoperative following shoulder surgery. The client has a prescription to keep the affected arm adducted. Which of the following instructions should the nurse share with the client? A. "Keep your arm bent at the elbow." B. "Use a pillow to prop your shoulder up close to your ear." C. "Hold your arm against the side of your body." D. "Position your arm with the shoulder at a 90° angle."
C. "Hold your arm against the side of your body."
A nurse is teaching a client who tested positive for an allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergen through which of the following statements? A. "I will begin vacuuming once a week." B. "Carpeting the entire house will be very expensive, but it will be worth it." C. "I will put a mattress cover on my bed." D. "Installing curtains on the windows will help control the dust in my house."
C. "I will put a mattress cover on my bed."
A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following pieces of information should the nurse include in the teaching? A. "PCP is sexually transmitted from person to person." B. "You were most likely exposed to a contaminated surface such as a drinking glass." C. "PCP results from an impaired immune system." D. "You might have contracted PCP from a family pet."
C. "PCP results from an impaired immune system."
A client who has thrombocytopenia asks the nurse why platelets are so important. Which of the following responses should the nurse make? A. "Platelets help the body fight infection." B. "Platelets help break down clots in the body." C. "Platelets plug breaks in blood vessels." D. "Platelets produce the molecules that carry oxygen."
C. "Platelets plug breaks in blood vessels."
A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? A. "Two tubes were necessary due to excessive bleeding from the area of the surgery." B. "The tubes drain blood from 2 different lung areas." C. "The lower tube will drain blood, and the higher tube will remove air." D. "The second tube will take over if blood clots block the first tube."
C. "The lower tube will drain blood, and the higher tube will remove air."
A nurse is providing teaching to a client who has type 2 diabetes mellitus. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following responses should the nurse provide? A. "Let's discuss this with your doctor; giving up daily pasta may not be necessary." B. "Is there another favorite dish you can substitute?" C. "You don't have to give up pasta; just adjust the amount you eat." D. "You can use no-added-salt tomato products on your pasta."
C. "You don't have to give up pasta; just adjust the amount you eat."
A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should return to the expected reference range within 72 hr of treatment beginning? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase
C. Amylase
A nurse is providing teaching to a client who has a new diagnosis of Menière's disease. Which of the following instructions should the nurse include in the teaching? A. Avoid bearing down B. Increase caffeine intake C. Avoid sudden movements D. Increase sodium intake
C. Avoid sudden movements
A nurse is talking with a group of women at a community center about the current recommendations for early detection of breast cancer. The nurse should explain which of the following options? A. Begin monthly breast self-examinations at age 40 B. Have a clinical breast examination each year after age 30 C. Begin annual mammograms at age 40 D. Have breast magnetic resonance imaging every 5 years after age 50
C. Begin annual mammograms at age 40
A nurse is assessing a client who has Addison's disease. Which of the following skin manifestations should the nurse expect to find? A. Purple striae on the chest and abdomen B. Butterfly rash across the bridge of the nose C. Bronze pigmentation of the skin D. Jaundice of the face and sclera
C. Bronze pigmentation of the skin
A nurse is performing medication reconciliation for a newly admitted client who has rheumatoid arthritis (RA). Which of the following medications should the nurse identify as the treatment for this condition? A. Misoprostol B. Dantrolene C. Celecoxib D. Colchicine
C. Celecoxib
A nurse is caring for a client who had a nephrostomy tube inserted 8 hours ago. Which of the following actions should the nurse include in the client's plan of care? A. Flush the nephrostomy tube every 4 hours with sterile water. B. Clamp the nephrostomy tube intermittently to establish continence. C. Check the skin at the nephrostomy site for irritation from urine leakage. D. Monitor for and report any blood-tinged drainage to the provider immediately.
C. Check the skin at the nephrostomy site for irritation from urine leakage.
A nurse in a dermatology clinic is using the ABCDE method while screening several skin lesions for skin cancer on a client. Which of the following findings should the nurse report to the provider? A. Symmetric shape B. Border regularity C. Color variation within a lesion D. Diameter >4 mm
C. Color variation within a lesion
A nurse is planning care for a client who has cholelithiasis. Which of the following interventions should the nurse include in the plan? A. Restrict the client's fluid intake B. Restrict the client's calcium intake C. Decrease the client's fat intake D. Decrease the client's potassium intake
C. Decrease the client's fat intake
A nurse is preparing a client who has a brain tumor for computed tomography (CT). Which of the following factors affects the manner in which the nurse will prepare the client for the scan? A. No food or fluids consumed for 4 hr B. Difficulty recalling recent events C. Development of hives when eating shrimp D. Paresthesias in both hands
C. Development of hives when eating shrimp
A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first? A. Provide chest physiotherapy B. Perform oropharyngeal suction C. Encourage deep-breathing and coughing D. Assist the client with ambulation
C. Encourage deep-breathing and coughing
A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following pieces of information should the nurse include in the teaching? A. Hospitalization is required when administering each treatment. B. The maximum effect of the medication will occur in 6 months. C. Hypertension is a common adverse effect of this medication. D. Blood transfusions are needed with each treatment.
C. Hypertension is a common adverse effect of this medication.
A nurse is assessing a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment? A. Inability to remember current age B. Inability to count backward C. Inability to locate eyeglasses D. Inability to recall names of family members
C. Inability to locate eyeglasses
A nurse is teaching a client who has hyperthyroidism about managing this disorder. Which of the following recommendations should the nurse include? A. Reduce total hours of sleep B. Keep the immediate environment warm C. Increase caloric intake with meals D. Gradually increase activity
C. Increase caloric intake with meals
A nurse is caring for a client who has abdominal pain and possible pancreatitis. Which of the following laboratory results should the nurse identify as an indication of pancreatitis? A. Decreased white blood cell (WBC) count B. Increased albumin level C. Increased serum lipase level D. Decreased blood glucose level
C. Increased serum lipase level
A nurse is teaching a client with systemic lupus erythematosus who has a new prescription for prednisone. The nurse should instruct the client to monitor for which of the following adverse effects of this medication? A. Hypoglycemia B. Tendinitis C. Infection D. Weight loss
C. Infection
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. The nurse notes no drainage in the client's urinary drainage bag over 1 hr. Which of the following actions should the nurse take? A. Instruct the client to attempt to void around the indwelling urinary catheter B. Increase the rate of irrigation fluid instillation C. Irrigate the indwelling urinary catheter with a syringe D. Prepare to administer a diuretic
C. Irrigate the indwelling urinary catheter with a syringe
A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? A. Metered-dose inhaler B. Continuous passive motion machine C. Oral-nasal suction equipment D. External defibrillator pads
C. Oral-nasal suction equipment
A nurse is caring for a client who has a depressed skull fracture of the bone that makes up the larger part of the upper and side wall of the cranium. This fracture is located on which of the following bones? A. Sphenoid B. Occipital C. Parietal D. Frontal
C. Parietal
A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? A. Infective endocarditis B. Pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli
C. Ventricular dysrhythmias
A nurse is caring for a client who has a new diagnosis of pernicious anemia. The nurse should expect the client's provider to prescribe which of the following medications for this client? A. Ferrous sulfate B. Epoetin alfa C. Vitamin B12 D. Folic acid
C. Vitamin B12
A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first? A. Hang an IV infusion of 0.9% sodium chloride with the blood B. Compare the client's identification number with the number on the blood C. Witness the informed consent document D. Obtain pretransfusion vital signs
C. Witness the informed consent document
A nurse is working with an assistive personnel (AP) who is assigned to bathe a client with herpes zoster. The AP asks the nurse if herpes zoster is contagious. Which of the following responses should the nurse make? A. "Adults receive natural immunity to herpes zoster from casual exposure to children who have had chickenpox." B. "Herpes zoster is not contagious to individuals who received an MMR vaccine as an infant." C. "A client who has herpes zoster is not contagious if blisters are present on the skin." D. "Herpes zoster is not contagious to people who have had chickenpox."
D. "Herpes zoster is not contagious to people who have had chickenpox."
A nurse is providing teaching about food choices to a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to eliminate sweet desserts from my diet." B. "I should avoid using sucralose in my coffee." C. "I should consume alcohol between meals in moderation." D. "I should replace white bread with whole-grain bread."
D. "I should replace white bread with whole-grain bread."
A nurse is providing teaching to a client who is preoperative prior to a transurethral resection of the prostate (TURP). Which of the following client statements indicates an understanding of the information? A. "I will not need to have a urinary catheter following this procedure." B. "I will expect my urine to be cloudy after having this procedure." C. "At least I won't have leakage of urine after having this procedure." D. "I will feel the urge to urinate following this procedure."
D. "I will feel the urge to urinate following this procedure."
A nurse is teaching a client who has a new prescription for alendronate for the treatment of osteoporosis. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take the medication in the evening." B. "I will drink a full glass of milk with the medication." C. "I will take the medication at mealtime." D. "I will sit upright after taking the medication."
D. "I will sit upright after taking the medication."
A nurse is assessing a 66-year-old client during a routine physical examination. This is the client's first clinic visit, and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies, "I am not sure, but it's been at least 5 years since I've had any immunizations." Which of the following responses should the nurse provide? A. "In case you had the immunization before, we can't give you another one." B. "You'll need a series of 3 injections." C. "This immunization is unsafe for people over the age of 65 years old." D. "Let's go ahead and give you this immunization."
D. "Let's go ahead and give you this immunization."
A nurse is planning discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include? A. "Avoid the use of NSAIDs." B. "Stop taking the corticosteroids when your symptoms resolve." C. "Exposure to ultraviolet light will help control the skin rashes." D. "Monitor your body temperature and report any elevations promptly."
D. "Monitor your body temperature and report any elevations promptly."
A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? A. "Move between the bed and the wheelchair once every 2 hr." B. "Make sure that your caregiver massages your skin daily." C. "Use a rubber ring when sitting on the bedside." D. "Shift your weight in the wheelchair every 15 min."
D. "Shift your weight in the wheelchair every 15 min."
A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following pieces of information should the nurse include in the teaching? A. "Wear nylon socks with shoes." B. "Wear flip flops instead of going barefoot when outside." C. "Apply moisturizing cream between your toes." D. "Wash your feet daily using lukewarm water and soap."
D. "Wash your feet daily using lukewarm water and soap."
A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride
D. 0.9% sodium chloride
A nurse in the emergency department is preparing to discharge a client following a Grade II (moderate) ankle sprain. Which of the following instructions should the nurse plan to give to the client? A. Perform passive range-of-motion exercises of the ankle hourly B. Keep the affected extremity in a dependent position C. Wrap a loose dressing around the affected ankle D. Apply cold compresses to the extremity intermittently
D. Apply cold compresses to the extremity intermittently
A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? A. Tracheostomy placement B. Thoracentesis C. CT scan of the chest D. Chest tube insertion
D. Chest tube insertion
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP). After the nurse discontinues the client's urinary catheter, which of the following findings should the nurse report to the provider? A. Pink-tinged urine B. Report of burning upon urination C. Stress incontinence D. Decreased urine output
D. Decreased urine output
A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching? A. High-pitched sound heard in the ear B. Intermittent rapid eye movement C. Itching of the external canal D. Feeling of fullness in the ear
D. Feeling of fullness in the ear
A nurse is caring for a client who is postoperative following a rhinoplasty. Which of the following findings should the nurse report to the surgeon? A. Nasal edema B. Mouth breathing C. Periorbital ecchymosis D. Frequent swallowing
D. Frequent swallowing
A nurse in the emergency department is caring for a client who has Addison's disease and reports nausea, vomiting, diarrhea, and abdominal pain. To prevent an Addisonian crisis, the nurse should prepare to administer which of the following medications? A. Calcium B. Potassium C. Iodine D. Hydrocortisone
D. Hydrocortisone
A nurse is caring for a client who underwent radioallergosorbent (RAST) testing due to seasonal allergies. The nurse should anticipate an elevation in which of the following immunoglobulin laboratory values? A. IgM B. IgA C. IgG D. IgE
D. IgE
A nurse is teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse include? A. Smoking cessation B. Benefits of a diet high in cruciferous vegetables C. New types of ostomy appliances D. Importance of colonoscopy screening starting at age 50 years old
D. Importance of colonoscopy screening starting at age 50 years old
A nurse is assessing a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction? A. Bradycardia B. Paresthesia C. Hypertension D. Low back pain
D. Low back pain
A nurse is caring for a client who is receiving radiation therapy for mouth cancer and reports a dry mouth. Which of the following dietary recommendations should the nurse provide? A. Offer graham crackers as a snack B. Avoid foods containing citrus C. Rinse the mouth with an alcohol-based mouthwash before eating D. Use gravies or sauces to soften food
D. Use gravies or sauces to soften food
A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client? A. Simple face mask B. Nonrebreather mask C. Bag-valve-mask device D. Nasal cannula
D. Nasal cannula
A nurse is teaching a client who has osteoporosis. Which of the following instructions should the nurse include in the teaching? A. Reduce dietary protein intake B. Apply ice to painful areas C. Increase calcium intake to 900 mg per day D. Perform weight-bearing exercises
D. Perform weight-bearing exercises
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following adverse effects? A. Diarrhea B. Increased serum albumin C. Hypoglycemia D. Peritonitis
D. Peritonitis
A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? A. Plethoric appearance of facial skin B. Glossitis and weight loss C. Jaundice with an enlarged liver D. Petechiae and ecchymosis
D. Petechiae and ecchymosis
A nurse is caring for a client who is concerned about the possibility of contracting Lyme disease after receiving a tick bite. For which of the following early manifestations of Lyme disease should the nurse assess the client? A. Diffuse maculopapular rash B. Dyspnea C. Double vision D. Progressive circular rash
D. Progressive circular rash
A nurse is caring for a client who will receive brachytherapy to treat uterine cancer. The nurse should ensure the client understands that she will receive which of the following interventions? A. Chemotherapy via a central venous access device B. Radiation to the tumor from an external source C. Precise delivery of high-dose radiation after tumor imaging D. Radioactive infusions or insertions into or near the tumor
D. Radioactive infusions or insertions into or near the tumor
A nurse is caring for a client who has dementia and is experiencing anxiety. Which of the following actions should the nurse take? A. Place a vest restraint on the client to protect others in the environment B. Provide a variety of routines to keep the client from getting bored C. Explain to the client that episodes of anxiety will decrease over time D. Redirect the client to a different activity with a small group of people
D. Redirect the client to a different activity with a small group of people
A nurse is providing teaching to a client who has a new diagnosis of myasthenia gravis (MG). Which of the following pieces of information should the nurse include? A. Use enemas to treat constipation caused by daily medications B. Take a hot bath when muscles ache C. Eat a low-calorie diet D. Set an alarm to ensure medication dosages are taken on time
D. Set an alarm to ensure medication dosages are taken on time
A nurse is conducting discharge teaching about foot care for a client who has diabetes mellitus. Which of the following instructions should the nurse include? A. Wear nylon socks with shoes every day B. Trim toenails by rounding the edges of the nail C. Apply lotion between the toes after bathing D. Test water temperature with the wrist
D. Test water temperature with the wrist
