ATI MedSurg - FINAL

a nurse is working with an assitive personnel (AP) who is assigned to bathe a client who has herpes zoster. the AP asks the nurse if herpes zoster is contagious. which of the following responses should the nurse make?

"Herpes zoster is contagious to people who have never had chickenpox." - inform the AP that varicella zoster is the causative agent of both chickenpox and herpes zoster. this virus is contagious to people who have not had chickenpox or have not received vaccination for varicella - the nurse should inform the AP that adults do not develop a natural immunity to chickenpox. this immunity is acquired through the development of chickenpox or by receiving vaccination for varicella - the nurse should inform the AP that herpes zoster is not contagious to people who have received vaccination for varicella. the MMR vaccine does not provide protection against herpes zoster - the nurse should inform the AP that herpes zoster is most contagious while fluid-filled blisters are present on the skin

a nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. which of the following statements by the client indicates an understanding of the teaching?

"I should check my hear rate each day." - the client should check his heart rate each day and to document the rate in a log for communication to the provider. instruct the client to notify the provider if the heart rate is below the prescribed parameters - pacemaker maintains a regular HR but is not intended to lower blood pressure or control HTN - avoid lifting the arm and shoulder on the side of the pacemaker until activity restrictions are removed by the provider. raising the arm and shoulder increases the risk of dislodgement of the pacemaker leads - it is safe to operate and be near a microwave oven

a nurse is reinforcing discharge teaching with 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?

"I should take ibuprofen for my joint pain." - the nurse should inform the client that SLE is an autoimmune disorder characterized by edacerbations and remissions. if affects the skin as well as joints, organs, and any structure in the body that contains connective tissue. NSAIDs, such as ibuprofen, are helpful if taken on a regular schedule in reducing the client's joint pain the nurse should inform the client that discoid lupus erythematosus only affects the skin; however, SLE affects the skin as well as joints, organs and any structure in the body that contains connective tissue - inform the client of the need to protect the skin from sun exposure to reduce the incidence of exacerbations. the nurse should recommend that the client use a sunblock with a sun protection factor of at least 30 - the nurse should inform the client that an elevated temperature is an indication of an exacerbation, the client should report this finding to the provider immediately

a nurse is reinforcing teaching with a client who has stomatitis due to chemotherapy. which of the following statements by the client indicates a need for further instructions?

"I will cleanse my mouth after meals with an alcohol-based mouthwash." - this client statement indicates a need for further reinforcement of teaching. clients with stomatitis need to avoid the use of alcohol-based mouthwash because it can irritate and burn the mucous membrane - provide oral care with a soft toothbrush or foam swab to prevent additional trauma or bleeding to oral tissues - use a straw when drinking liquids to reduce the amount of exposure of liquids on the oral mucosa, decreasing irritation - rinse the mouth often with hydrogen peroxide, warm saline, or baking soda solution to promote comfort and healing

a nurse is reinforcing discharge teaching with a client who has infective endocarditis about how to prevent recurrence. which of the following statements by the client indicates an understanding of the teaching?

"I will notify my doctor before I have dental procedures." - the nurse should inform the client of ways to decrease the risk recurrence of infective endocarditis. the client should notify the provider prior to invasive or dental procedures due to the need for prophylactic antibiotic therapy to reduce the risk of a streptococcal infection - the nurse should inform the client that body piercings increase the risk of bacteremia. which can result in recurrence of infective endocarditis. the client should avoid obtaining any body piercings whether or not he has a fever - the nurse should inform the client that good oral hygiene reduces the risk of recurrence of infective endocarditis. the client should, however, avoid the use of floss, which increases the risk of oral trauma and a streptococcal infection - the nurse should inform the client that it is not necessary to wear a mask when going out in public because infective endocarditis does not result in immunosuppression. the client should, however, avoid contact with individuals who have a streptococcal infection

a nurse is reinforcing teaching with a client who is scheduled for a sigmoid colon restriction with colostomy. which of the following statements by the client indicates a need for further teaching?

"My diet will have to change to a soft diet after surgery." - the nurse should identify that this statement requires further reinforcement of teaching. after surgery, the client's diet quickly returns to a regular diet and there are not any food restrictions, unless the client chooses to decrease intake of foods that increase gas or odor - the nurse should inform the client that a colostomy placed at the descending or sigmoid colon produces stool that is fairly solid and resembles that which normally expelled from the rectum, therefore, this statement does not require further reinforcement of teaching - inform the client that the stoma is edematous at first because of trauma from surgery and manipulation of the colon, but that it will shrink after surgery as the edema decreases, therefore, this statement does not require further reinforcement of teaching - the nurse should inform the client that because of the lack of bowel peristalsis after surgery and the client's NPO status, it is not usual to see only mucous drain from the ostomy until 2 to 6 days after surgery. therefore, this statement does not require further reinforcement of teaching

a nurse is reinforcing discharge teaching with a client who has AIDS. which of the following statements should the nurse include?

"You should clean bathroom surfaces with a bleach and water solution." - the nurse should inform the client of the need to clean bathroom surfaces with 1:10 bleach and water solution to provide adequate disinfection and infection control - the nurse should inform the client of the need to avoid sharing razors and other personal care items to reduce the risk of transmission through blood or body fluids - the nurse should inform the client who has AIDS of the need to avoid raw fruits and vegetables to reduce the risk of infection due to immunosuppression - the nurse should inform the client of the need to avoid gardening or other activities that provide exposure to soil. wearing a mask does not provide adequate protection from contact from soil and increases the client's risk for infection due to immunosuppression

a nurse is reinforcing teaching with a client who has TB and a prescription for isoniazid. which of the following instructions should the nurse include?

"Your provider will monitors your liver function while you are taking this medication." - the nurse should inform the client that the provider will monitor the client's liver function while taking isoniazid due to the risk for hepatotoxicity - the nurse should instruct the client that therapy usually lasts 6 to 9 months. the nurse should emphasize the need for compliance during the course of treatment for medication effectiveness - the nurse should instruct the client to avoid alcohol intake while taking isoniazid due to the increased risk of adverse effects - the nurse should instruct the client to take isoniazid on an empty stomach to increase absorption

a nurse is reinforcing teaching with a client who has a new diagnosis for multiple sclerosis (MS). the client asks the nurse about the usual course of MS. which of the following responses should the nurse make?

"acute episodes are usually followed by remissions, which can last varying lengths of time." - the nurse should inform the client that MS is a chronic autoimmune disorder that is characterized by remission and exacerbations. which exacerbations becoming more frequent and intense as the disease progresses

a nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight management program. the nurse determines that the client gained 1.36 kg (3 lb) in the past week. which of the following statements should the nurse make?

"were there any issues last week that kept you from focusing on your diet?" - the nurse should use an open-ended question that allows the client to reassess the past week in a nonthreatening manner. the nurse's statement demonstrates concern without placing blame. the nurse should explain to the client that relapse is a normal part of making a behavior change, and that physical and emotional stress can play a part in his motivational level - the nurse should avoid direct blame towards the client, which can result in a defensive response and decrease motivation - the nurse should avoid the use of "why" questions, which can promote a defensive client response - the nurse should avoid providing the client with approval or personal advice, which does not promote a professional nurse-client relationship

a nurse is preparing to care for a group of clients after receiving change-of-shift report. from which of the following clients should the nurse collect data first?

a client who has emphysema and reports dyspnea - apply the ABC priority-setting framework. the nurse should first collect data from a client who has emphysema and reports dyspnea, or SOB - the nurse should collect data from a client who has BPH and reports dysuria, however, this is an expected finding for BPH. the nurse should collect data from a different client first - the nurse should collect data from the client who has ulcerative colitis and reports diarrhea, however, this is an expected finding for ulcerative colitis. the nurse should collect data from a different client first - the nurse should collect data from the client who has esophageal cancer and reports painful swallowing. however, this is an expected finding for esophageal cancer. the nurse should collect data from a different client first

a nurse is reinforcing teaching with a client about how to perform a breast self exam (BSE). the nurse should identify which of the following findings as an indication of breast cancer?

a nontender, hard lump that is palpated in one breast - cancerous tumors are typically hard, fixed, irregular in shape, and nontender to palpation. the nurse should instruct the client to notify the provider promplty if she palpates a hard, nontender lump - moveable lumps that increase in tenderness during the menstrual period as an indication of fibrocystic breast tissue - multiple masses of regular shaped in both breasts are characteristic of fibrocystic breast disease - bilaterally darkened areolas are an expected finding in dark-skinned women and an expected change during pregnancy in light-skinned women

a nurse is contributing to the plan of care for a client during a sickle cell crisis. which of the following interventions should the nurse recommend?

administer oxygen via nasal cannula - the nurse should administer oxygen to the client during a sickle cell crisis. hypoxia increases sickling and client discomfort - the nurse should promote client rest because increased activity increases sickling and client discomfort - the nurse should keep the room warm during a sickle cell crisis and apply warm, moist compresses to painful joints. this application of cold compresses causes vasoconstriction, which in turn increases sickling - the nurse should ensure that the client receives opioids, including morphine and hydromorphone, on a routine schedule during a crisis to manage the client's pain

a community health nurse is reinforcing teaching about melanoma with a group of clients. which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching?

an irregular border - skin cancer lesions, including melanoma, are expected to exhibit border irregularity. the nurse should reinforce teaching with client about appearance of melanoma lesions, including asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature - skin cancer lesions, including melanoma, are expected to exhibit color variation - skin cancer lesions, including melanoma, are expected to exhibit asymmetry in shape - skin cancer lesions, including melanoma, are expected to exhibit a diameter that is greater than 6 mm

a nurse is preparing to administer timolol eye drops for a client who has glaucoma. when instilling the medication, which of the following actions should the nurse take?

apply pressure to the bridge of the nose after instillation of the medication - the nurse should instill timolol into the conjunctival sac and apply pressure to the bridge of the nose for 1 min afterwards to prevent systemic absorption of the medication - the nurse should instruct the client to gently close the eyes and to avoid blinking after instillation to prevent loss of medication out of the eye and to promote absorption - the nurse should instruct the client to look upward toward the ceiling during instillation of the medication to allow for proper placement of the medication and to suppress the client's blink reflex - the nurse should instill the medication into the client's conjunctival sac and should take measures to protect the client's cornea during administration of the medication

a nurse is collecting data from a client who has asthma and reports several food allergies. which of the following actions should the nurse take first?

ask the client to identify the specific food allergies - the nurse should apply the nursing process priority-setting framework. the first action the nurse should take is to collect data about the client's allergies and identify the specific allergens so that the nurse can ensure that the specific foods are not offered to the client during meals - the nurse should document the client's food allergies on the medical record to communicate the information to other members of the health care team, however, there is another action that the nurse should perform first - the nurse should monitor the client for indications of anaphylaxis due to allergen exposure, however, there is another action the nurse should perform first - the nurse should have epinephrine available for administration to treat the manifestations of an allergic reaction, however, there is another action that the nurse should perform first

a nurse is reinforcing dietary teaching with a client who has DM. which of the following actions should the nurse take first?

asks the client to identify the types of foods she prefers. - the nurse should apply the nursing process priority-setting framework. the nurse should first ask the client about individual food preference to provide an opportunity for the nurse to include these foods in her diet. involving the client in the planning will help promote her adherence to the dietary plan - the nurse should work with a registered dietitian to provide the client with appropriate materials to use during reinforcement of dietary teaching. sample menus can be helpful in providing the client with ideas for new foods or exchanges. however, there is another action that the nurse should take first - the nurse should identify the recommended blood glucose range that the client should maintain through diet, medication, and lifestyle changes. however, there is another action that the nurse should take first - the nurse should identify the long-term complications so the client understands the importance of adherence to the dietary plan, however, there is another action that the nurse should take first

a nurse is contributing to the plan of care for a client who is 72 hr postoperative following an above-the-knee amputation. which of the following actions should the nurse recommend?

assist the client to prone position every 4 hr - the nurse should assist the client to prone position for 20 to 30 min every 3 to 4 hr following an amputation to reduce the risk of flexion contractures - the nurse should avoid elevation of the residual limb 72 hr following an amputation because this position increases the client's risk for hip flexion contractures - the nurse should reapply a bandage to the residual limb every 4 to 6 hr to assist in preparation for a prosthetic limb - the nurse should apply bandages to the residual limb in a distal-to-proximal direction using a figure-of-eight pattern to prevent restriction of blood flow

a nurse is caring for a client who is to have his chest tube removed. which of the following actions should the nurse take?

auscultate the lungs after removal - the nurse should auscultate the client's lungs after the chest tube is removed to monitor for the development of a pneumothorax - the nurse should cover the insertion site with an occlusive dressing to prevent air entry into the pleural space - the nurse should provide the client with pain medication prior to the procedure to promote comfort during the removal of the chest tube - the nurse should expect a provider or specially trained RN to remove the client's chest tube. the nurse should not delegate this procedure to an AP, as it is beyond the AP's scope of practice

a nurse is contributing to the plan of care for a client who has thrombocytopenia due to chemotherapy. which of the following interventions should the nurse include?

avoid IM injections - the nurse should identify that a client who has thrombocytopenia is at risk for bleeding. therefore, the nurse should avoid invasive procedures such as an IM injection - the nurse should avoid any procedure, such as obtaining a rectal temperature, that can cause trauma to rectum and increase the client's risk for rectal bleeding - the nurse should limit visitors for a client who has neutropenia, but does not need to disallow visitors - the nurse should promote safe oral hygiene, but should instruct the client to avoid flossing due to the risk for bleeding

a nurse is collecting data from a client who develops a fruity breath odor, dry mouth, and extreme thirst. which of the following additional data should the nurse collect?

blood glucose using a glucometer - the nurse should identify that the client's manifestations are indications of hyperglycemia and diabetic ketoacidosis. the nurse should therefore check the client's blood glucose level. the nurse should also check the client's respiratory status, vital signs, level of consciousness, and hydration status, including his electrolyte levels - identify the probable cause of the client's manifestation and perform a focused data collection of the affected system, therefore, it is not necessary for the nurse to check the client's pupillary reaction to light - it is not necessary for the nurse to check the client's deep tendon reflexes - it is not necessary to check the client's liver function

a nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). which of the following actions should the nurse take? (SATA)

check and document the client's vital signs - the nurse should check and document the client's vital signs prior to a blood transfusion to obtain a baseline for comparison. monitoring the client's vital signs helps the nurse identify adverse reactions to the packed RBCs and identify if the client is tolerating the volume of the prescribed blood product verify that the blood type and Rh of the packed RBCs are checked by two nurses - the nurse should verify that two nurses check the blood type and Rh of the packed RBCs and compare with the client's information for compatibility. this action decreases the risk of an ABO incompatibility reaction provide the RN with IV tubing that has a filter - the nurse should provide the RN with IV tubing that has a filter to prevent the administration of aggregates and possible contaminants - the nurse should ensure that the client has a 20-gauge or larger needle for administration of packed RBCs to prevent the formation of blood clots during transfusion - the nurse should obtain a bag of normal saline IV solution for administration with the packed RBCs. lactated ringer's solution is not used because it causes clotting and hemolysis of the blood cells

a nurse is caring for a client who has stage III pressure ulcer on his heel. when preparing to irrigate the wound, which of the following actions should the nurse take first?

check the client's pain level - the nurse should apply the nursing process priority-setting framework. the nurse should assess the client's pain level prior to administration of an analgesic. medicating the client approximately 30 min prior to wound care will decrease pain and increase her comfort - the nurse should obtain the prescribed irrigation solution prior to performing the procedure, however, there is another action the nurse should take first - the nurse should don personal protective equipment prior to performing the procedure to prevent exposure to blood or body fluids from the client's wound. however, there is another action the nurse should take first - the nurse should place a waterproof pad under the client's extremity to protect the linens from moisture and contamination during the irrigation, however, there is another action the nurse should take first

a nurse is collecting data from a client who has a fractured left femur and is in skeletal traction. which of the following findings should the nurse identify as an indication of fat emboli to report to the provider?

chest petechiae - the nurse should identify chest petechiae as an indication of a fat embolism. clients who have fractures of the long bones, such as the femur, are at increased risk for fat emboli. fat emboli typically occur 12 to 48 hr after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. the nurse should immediately notify the provider as the client could progress into acute respiratory failure - the nurse should identify ecchymosis of the thigh as an expected finding for a client who has a fractures left femur - the nurse should identify that serous drainage is expected at the pin site for a client who is in skeletal traction. the nurse should monitor for purulent drainage that can indicate an infection at the site - the nurse should identify muscle spasms in the left leg as an expected finding for a client who has fractured left femur

a nurse is reinforcing teaching about a low-cholesterol diet with a client who had a myocardial infarction. which of the following meal selections by the client indicates an understanding of the teaching?

chicken breast and corn on the cob - the nurse should identify that chicken and all vegetables, including corn, are cholesterol free. therefore, this food selection by the client indicates an understanding of the teaching - the nurse should inform the client that shrimp are high in cholesterol and should be eaten in moderation, therefore, this food selection does not indicate an understanding of low-cholesterol diet - the nurse should inform the client that eggs and cheese are high in cholesterol; therefore this food selection does not indicate an understanding of a low-cholesterol diet - the nurse should inform the client that liver and other organ meats are high in cholesterol, therefore, this food selection does not indicate an understanding of a low-cholesterol diet

a nurse in an urgent care clinic is collecting data from a client who sustained a fall. which of the following findings should the nurse identify as an indication of a skull fracture?

clear fluid coming from the nares - the nurse should identify cerebrospinal fluid, which appears as a clear fluid, coming from the nares or ears as an indication of a skull fracture - a headache in a client who sustained a fall as an indication of a possible concussion. the nurse should collect additional data to determine if additional injuries, such as a skull fracture, are present - the nurse should identify a brief change in the client's LOC as an indication of a possible concussion. the nurse should collect additional data to determine if additional injuries, such as a skull fracture, are present - though a client who has bleeding from the scalp might also have additional head trauma, this finding does not indicate a skull fracture. the nurse should collect additional data to determine if additional injuries, such as a skull fracture, are present

a nurse is caring for a client who has type 1 DM and a capillary blood glucose reading of 48 mg/dL. which of the following findings should the nurse expect?

diaphoresis - clients with blood glucose level below 70 mg/dl are going to exhibit indications of hypoglycemia. expected findings associated with hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness and confusion - Kussmaul respirations are expected in clients with hyperglycemia - the nurse should expect dehydration and decreased skin turgor in a client who has hyperglycemia - a nurse should expect ketonuria in an client who has hyperglycemia

a nurse is caring for a male client who is undergoing screening tests for atherosclerosis. which of the following laboratory findings should the nurse identify as an increased risk for this disorder?

elevated LDL levels - the nurse should identify that an elevated LDL level increases the client's risk for atherosclerosis. the client's desirable LDL is below 130 mg/dl - the nurse should identify that total cholesterol levels less than 200 mg/dl are recommended to help reduce the incidence of developing atherosclerosis - the nurse should expect a decreased HDL level in a client who is at risk for atherosclerosis. elevated HDLs have a protective effect against the development of atherosclerosis. the client's desirable HDL level is 35 to 65 mg/dL - the nurse should identify that triglyceride levels less than 150 mg/dl are recommended to help reduce the incidence of atherosclerosis

a nurse is reinforcing teaching with a client about preventing the transmission of hepatitis A. the nurse should identify that hepatitis A is transmitted by which of the following routes?

fecal-oral contamination - hepatitis A is most commonly transmitted by the fecal-oral route. transmission occurs by ingesting food or liquid that has been infected with the virus. outbreaks due to contaminated food are usually due to poor hygiene practices by food handlers or shellfish from contaminated water - hepatitis B, rather than hepatitis A, is transmitted by several routes, including the maternal-fetal route - hepatitis B, C, and D rather than hepatitis A, are transmitted by several routes, including unprotected sexual intercourse - that hepatitis B and C, rather than hepatitis A, are transmitted by several routes, including blood to blood exposure

a nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. which of the following personal protective equipment (PPE) should the nurse don prior to providing client care? (SATA)

gown - follow standard precautions when caring for a client who has AIDS. because the bed linens might be soiled,the nurse should don a gown in addition to other necessary PPE gloves - standard precautions for client who has AIDS. because the nurse's hands will come into contact with the soiled bed linens, the nurse should don clean gloves in addition to other necessary PPE - mask is not needed when changing the client's bed linens - hair cover is not needed when changing the client's bed linens - goggles is not needed since splashing of bodily fluids is unlikely when changing the client's bed linens

a nurse in a provider's office is caring for a client who has blepharitis. which of the following actions should the nurse take first?

inspect the eyes for drainage or redness - use the nursing process priority-setting framework. the first action the nurse should take is to collect data for basic eye examination, including inspecting eyes for drainage or redness, which can indicate ocular irritation of infection - the nurse should expect the provider to prescribe antibiotic eyedrops for the treatment of blepharitis and should reinforce teaching on proper instillation, however, there is another action that should take first - the nurse should apply warm compresses to the affected eye to soften secretions for removal, however, there is another action that the nurse should take first - the nurse should dim the light in the examination room to decrease client discomfort from photophobia that commonly occurs with blepharitis, however, there is another action that the nurse should take first

a nurse is monitoring a client following a thyroidectomy. which of the following findings should the nurse identify as an indication of hypoparathyroidism?

involuntary muscle spasms - the nurse should identify involuntary muscle spasms as an indication of hypoparathyroidism, which can occur if the parathyroid glands are damaged or removed during a thyroidectomy. muscle twitching and paresthesias can result due to decreased parathyroid hormone level and calcium deficiency - the nurse should identify hypertension as an indication of thyroid storm, which is a potential complication following a thyroidectomy - the nurse should identify cold intolerance as an indication of hypothyroidism the nurse should identify weight loss as an indication of hyperthyroidism

a nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. which of the following actions should the nurse take first?

lower the client to the floor - apply the safe and risk reduction priority-setting framework. if the client begins to have a seizure while sitting or standing, the nurse should first lower the client to the floor to protect him from injury - the nurse might need to provide oxygen to the client during the postictal phase, however, there is another action the nurse should take first - the nurse should turn the client onto his side if possible to keep the airway clear, however, there is another action the nurse should take first - the nurse should provide privacy by closing the privacy curtain or the door to the client's room. however, there is another action the nurse should take first

a nurse is caring for a client who is receiving continuous enteral feedings. which of the following actions should the nurse take?

monitor the client's blood glucose level - monitor the client's capillary blood glucose level due to the client's risk of hyperglycemia while receiving enteral nutrition. the glucose level in the enteral nutrition solution places the client at risk for this complication - maintain the client in a semi-Fowler's position during continuous enteral feedings to decrease the risk of aspiration - the nurse should flush the enteral feeding tube with 30 ml of warm water before and after each medication to ensure delivery of the medication and prevent clogging of the tube - the nurse should verify that tube placement was confirmed by x-ray prior to beginning the feeding

a nurse is contributing to plan of care for a client who had a stroke. the client has hemiplegia and occasional urinary incontinence. which of the following interventions should the nurse recommend?

offer the client a bedpan every 2 hr - following a stroke, the client might have bladder incontinence due to confusion, impaired sensation in response to bladder fullness, and decreased sphincter control. the nurse should encourage and assist the client to void every 2 hr while awake to promote bladder control. by offering a bedpan, the nurse promotes client safety - the nurse should encourage adequate fluid intake to promote urine production. the nurse should also plan actions that promote bladder training - the nurse should avoid inserting an indwelling catheter due to the increased risk for a health care-associated urinary tract infection. the nurse should instead plan actions to promote bladder training - the nurse should promote client safety and plan actions that promote bladder training. ambulating a client who has hemiplegia every 30 min increases the risk for falls and does not allow time for the bladder to fill

a nurse is caring for a client who has thrombocytopenia and develops epistaxis. which of the following actions should the nurse take?

pinch the soft portion of the client's nose for 10 min - the nurse should apply direct pressure to the nose for 10 min to control epistaxis. if after 10 min the epistaxis continues, the client might require nasal packing or other interventions - the nurse should instruct the client to refrain from blowing his nose for 24 hr after the epistaxis stops. the formation of clots is the mechanism that will terminate the nosebleed. having the client blow his nose will dislodge any clots that do form and cause the bleeding to continue - the nurse should place the client in a sitting position, leaning forward. if the client positions his head and neck backward, it will allow blood to drain into the stomach, causing nausea and vomiting - the nurse should apply an ice pack or cool compress to the client's nose and face to help control epistaxis

a nurse is contributing to the plan of care for a client who has thrombophlebitis. which of the following actions should the nurse recommend for the plan of care?

place compression stockings on the lower extremities - the nurse should apply compression stockings on the client's lower extremities to promote blood return and decrease venous stasis - the nurse should apply warmth to the affected extremity for the treatment of thrombophlebitis - the nurse should avoid rubbing or massaging the affected area to prevent dislodging the thrombus - while thrombolytic medications can dissolve a thrombus, heparin does not. the nurse should inform the client that heparin prevents enlargement of the thrombus and further clot formation

a nurse is contributing to the plan of care for a client who has cancer and is scheduled to receive internal radiation therapy. which of the following actions should the nurse recommend?

place the client in a private room - the nurse should recommend placing the client in a private room during internal radiation therapy to prevent exposing other clients and visitors to radiation - the nurse should recommend that all staff assigned to care for the client wear dosimeter badges to monitor radiation exposure - the nurse should recommend that staff don a lead apron prior to entering the client's room to decrease radiation exposure. a cover gown provides protection from blood or body fluids but does not protect from radiation exposure - the nurse should recommend picking up dislodged implants with forceps and placing them in a lead container to prevent radiation exposure

a nurse is assisting with the care of a client who has a chest tube in place following a thoracotomy. which of the following actions should the nurse take?

place the drainage unit the below the client's chest level - the nurse should ensure that the drainage unit is below the client's chest level at all times to facilitate drainage by gravity - the nurse should maintain a closed system by replacing the drainage unit when it is full rather than routinely emptying it - the nurse should reinforce the dressing if needed but should avoid changing the insertion site dressing unless prescribed by the surgeon - the nurse should avoid clamping the chest tube to promote continued drainage and to decrease the risk of tension pneumothorax

a home health nurse enter a client's home and finds a used insulin syringe, without a cap, on the table. which of the following actions should the nurse take?

place the syringe in a puncture-proof disposal container - the nurse should place the uncapped syringe in a puncture-proof sharps disposal container or rigid plastic container to prevent a needlestick injury. the nurse should keep the syringe uncapped to prevent a needlestick injury while placing the cap on the needle. the nurse should then reinforce client education on safety and proper disposal of syringes - the nurse should not recap the needle because of the risk of needlestick injury during this action - the nurse should not schedule another nurse to administer future injections for the client. the nurse should reinforce teaching with the client about potential injuries and infections that can result from a needlestick injury. after exploring the client's reasons for nonadherence to safety measures, the nurse should review appropriate methods of disposal for used syringes - the nurse should not instruct the client to dispose of used syringes in a bathroom trash can due to the risk for a needlestick injury when handling the trash

a nurse is caring for a client following a hip arthroplasty. the nurse should place an abduction pillow on the client for which of the following purposes?

preventing dislocation of the hip during position changes or movement - following surgery, the nurse should use an abduction pillow to prevent dislocation of the new hip joint. the nurse should place the wedge-shaped pillow between the client's legs. the purpose of the abduction pillow is to prevent adduction beyond the midline of the body during position changes or client movement, which can lead to subluxation or total dislocation of the hip joint - if the client is at risk for plantar flexion resulting in foot drop, the nurse should place a foot cradle at the foot of the bed to raise bed linens off the feet and prevent plantar flexion - the nurse should use regular bed pillows to keep the client's heels off the bed to prevent skin breakdown - the nurse should use regular pillows and rolled blankets to position the client off the operative site while in bed

a nurse is reinforcing teaching with a client who has TB and a prescription for rifampin. the nurse should identify which of the following findings as a harmless and expected adverse effect of rifampin?

red-orange discoloration of urine - the nurse should instruct the client that rifampin commonly causes a red-orange discoloration of body fluids. this adverse effect is considered harmless and does not require reporting to the provider - ecchymosis is an indication of bleeding. the nurse should identify a prolonged bleeding time as an indication of thrombocytopenia, which is potentially life-threatening adverse effect of rifampin that should be reported to the provider immediately - the nurse should identify jaundice, including yellow appearance of the sclerae, as an indication of hepatotoxicity, which is a potentially serious adverse effect of rifampin that should be reported to the provider immediately - the nurse should identify malaise and fatigue and lack of energy as indications of hepatotoxicity, which is a potentially serious adverse effect of rifampin that should be reported to the provider immediately

a nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). which of the following actions should the nurse take?

report viscous drainage with clots to the provider - report urine output that is bright red with clots or urine that resembles ketchup to the provider, as this is an indication of hemorrhage - the nurse should irrigate the catheter with 0.9% sodium chloride to maintain a catheter patency - the nurse should ensure that the drainage catheter remain free of kinks and obstructions to maintain patency and prevent overdistention of the bladder - the nurse should identify that a client sensation of a strong urge to urinate is an expected manifestation after a TURP due to the pressure of the balloon on the bladder sphincter. the nurse should maintain catheter patency and bladder irrigation

a nurse is reviewing a client's laboratory report. the client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3 24 mEq/L. the nurse should perform that the client has which of the following acid-base imbalances?

respiratory alkalosis - the nurse should identify that the client's pH is elevated above the expected reference range of 7.35 to 7.45, indicating alkalosis. the nurse should then identify that the client's PaCO2 is low, below the expected reference range of 35 to 45 mmHg, which indicates respiratory origin. The nurse should conclude that the client's elevated pH and decreased PaCO2 indicates respiratory alkalosis - the nurse should recognize that ABGs are drawn to determine acid-base balance in the arterial blood. acidosis is determined reference by measuring a pH lower than the expected reference range of 7.35 to 7.45. this client has a pH of 7.5 and therefore does not have acidosis - the nurse should recognize that ABGs are drawn to determine acid-base balance in the arterial blood. the client's pH is elevated above the expected reference range. acidosis is presented by a lower pH, usually below 7.35 - the client does not have a metabolic origin for abnormal ABGs. Metabolic origin is determined by examining the HCO3 levels. the client's bicarbonate is WNL of 22 to 26 mEq/L

a nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. which of the following data should the nurse collect first?

respiratory rate - use the ABC priority-setting framework. the nurse's priority is to collect data about the client's respiratory status. a client who has burns to her face is at risk for pulmonary injury and the development of rapid, shallow respirations can indicate a respiratory emergency - the nurse should determine the percentage of the client's total body surface are that is burned to ensure proper care and estimation of prognosis, however, the nurse should collect other data first - nurse should monitor the client's bowel sounds due to the risk for a paralytic ileus; however, the nurse should collect other data first - nurse should check the client's level of pain and provide prescribed analgesics; however, the nurse should collect other data first

a nurse is collecting data from a client who has encephalitis due to West Nile virus. which of the following findings should the nurse expect? (SATA)

stiff neck - encephalitis is acute inflammation of the brain, therefore, the nurse should expect neurological manifestations, such as a client report of a stiff neck photophobia - encephalitis is acute inflammation of the brain, therefore, the nurse should expect neurological manifestations, such as photophobia lethargy - the client will also experience lethargy, which can progress to coma - the nurse should expect bilateral flaccid paralysis or movement disorders in a client who has encephalitis and unilateral weakness in a client who has a stroke - the nurse should expect neurological manifestations in a client who has encephalitis and epigastric pain in a client who has cardiac or GI disorder

a nurse is reinforcing teaching with a client who has gout and urolithasis. the client asks how to prevent future uric acid stones. which of the following suggestions should the nurse make? (SATA)

take allopurinol as prescribed - the nurse should inform the client that allopurinol is an antigout medication that reduces level of uric acid, which helps prevent uric acid stone formation exercise several times a week - inform the client that immobility is a risk factor for urinary stasis and stone formation, therefore, the client should maintain a healthy lifestyle, including regular exercise to help prevent stone formation limit intake of foods high in purine - the nurse should inform the client that purine increases the risk for uric acid stone formation. the nurse should identify that organ meats, poultry, fish, red wine, and gravies are high in purine - the nurse should inform the client that adequate fluid intake of 2 to 3 L per day reduces the risk of stone formation - the nurse should inform the client that citrus juices helps to alkalinize the urine, which helps prevent uric acid stone formation

a nurse is reinforcing teaching with a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). which of the following instructions should the nurse include in the teaching?

thoroughly shampoo hair prior the EEG - the client should thoroughly wash her hair prior to the EEG because hairsprays, oils, and other hair preparations interfere with recording results of the EEG - taking a sedative the night prior to the EEG is not recommended because sedative depresses CNS functioning and can alter EEG results - instruct the client to eat regularly scheduled meals prior to the EEG because a low blood glucose level resulting from NPO status can alter EEG results - the client should withhold or take anticonvulsant medication as prescribed by the provider. the client should not take an additional dose of medication, as this will decrease the likelihood of recording seizure activity and can result in an unsafe overdosage of medication

the nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. which of the following information should the nurse include in the teaching?

use pursed-lip breathing during periods of dyspnea - the nurse should instruct the client about the use of pursed-lip breathing during periods of dyspnea to slow expiration, increase airway pressure, and facilitate effective gas exchange - the nurse should instruct the client to drink at least 2,000 to 3,000 ml of fluids a day to keep respiratory secretions thin and easier to expectorate - the nurse should instruct the client to practice diaphragmatic or abdominal breathing, which helps to reduce the respiratory rate and increase alveolar ventilation - the nurse should instruct the client to maintain an SaO2 at least 88%. the client who has emphysema requires a lower arterial oxygen level to maintain the stimulation to breathe. maintaining a SaO2 of 94% or greater could suppress the client's breathing

a nurse is caring for a client who is scheduled to receive intermittent peritoneal dialysis. which of the following actions should the nurse take?

weight the client before and after each dialysis treatment - weight the client before and after each peritoneal dialysis Tx to maintain accurate intake and output adequate of the dialysate solution - apply sterile gloves and maintain strict aseptic technique when handling bags of dialysate fluid to reduce the risk of peritonitis - the nurse should keep the bags of dialysate fluid at room temperature - check the client's upper extremity peripheral circulation prior to hemodialysis due to placement of ateriovenous fistula for vascular graft. the client's peritoneal dialysis catheter is located in the abdomen