ATI MS 3
100. A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a complication of MG for which the nurse should monitor? 1) Respiratory difficulty 2) Confusion 3) Increased intracranial pressure 4) Joint pain
1
102. A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching? 1) "You should wear glasses instead of contacts while taking this medication." 2) "The medication causes amenorrhea if taken along with an oral contraceptive." 3) "A yellow tint to the skin is an expected reaction to the medication." 4) "Lifelong treatment with this medication is necessary.
1
106.A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching? 1) "I will keep my house at a cool temperature." 2) "I will try to anticipate and avoid stressful situations." 3) "I will complete the smoking cessation program I started." 4) "I will wear gloves when removing food from the freezer."
1
107.A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking ferrous sulfate twice a day. Which of the following statements by the client indicate an understanding of the teaching? 1) "I will take the medication with orange juice." 2) "I should expect to have loose stools while taking this medication." 3) "I will have clay colored stools while taking this medication." 4) "I should take the medication with milk."
1
108.A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia? 1) Vitamin B12 2) Vitamin C 3) Iron 4) Folate
1
111.A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take? 1) Empty the suction device every 4 hr. 2) Monitor circulation on the affected extremity every 2 hr for the first 12 hr. 3) Position the client's hip so that it is internally rotated. 4) Encourage foot exercises every 4 hr.
1
115.A nurse is collecting data from a client who has Cushing's syndrome. Which of the following manifestations should the nurse expect? 1) Bruising 2) Weight loss 3) Hyperpigmentation 4) Double vision
1
12.A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. 2) Place the client's affected leg into the CPM machine with the machine in the flexed position. 3) Place the client into a high Fowler's position when initiating the CPM exercises. 4) Align the joints of the CPM machine with the knee gatch in the client's bed.
1
122.A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective? 1) "I will take a stool softener until my eye is healed." 2) "I will expect to have moderately severe pain for 1-2 days." 3) "I will refrain from cooking for 1 week." 4) "I will bend at the waist to tie my shoes."
1
124.A nurse is caring for a client who has COPD. Which of the following actions should the nurse take? 1) Encourage the client to drink 8 glasses of water a day. 2) Instruct the client to cough every 4 hr. 3) Provide the client with a low protein diet. 4) Advise the client to lie down after eating.
1
126.A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease? 1) An expanding circular rash 2) Swollen, painful joints 3) Decreased level of consciousness 4) Necrosis at the site of the bite
1
127.A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastectomy with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm? 1) Combing her hair 2) Eating her breakfast 3) Buttoning her blouse 4) Tying her shoes
1
17.A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? 1) Altered level of consciousness 2) Oral temperature of 37.7° C (100° C) 3) Muscle spasms 4) Headache
1
18.A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? 1) Abdomen is distended 2) Chest tube drainage of 70 mL in the last hour 3) Subcutaneous emphysema is noted to the left chest wall 4) Pain level of 6 on a 0 to 10 scale
1
19.A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? 1) Change the ostomy pouch daily. 2) Empty the ostomy pouch when it is 2/3 full. 3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma. 4) Apply lotion to the peristomal skin when changing the ostomy pouch.
1
22.A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? 1) Loss of peripheral vision 2) Headache 3) Halos around lights 4) Discomfort in the eyes
1
26.A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? 1) Take this medication between meals. 2) Limit intake of Vitamin C while taking this medication. 3) Take this medication with milk. 4) Limit intake of whole grains while taking this medication
1
27.A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? 1) Take this medication between meals. 2) Limit intake of Vitamin C while taking this medication. 3) Take this medication with milk. 4) Limit intake of whole grains while taking this medication
1
31.A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? 1) Decreased color perception 2) Loss of peripheral vision 3) Bright flashes of light 4) Eyestrain
1
43.A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? 1) Airway obstruction 2) Infection 3) Fluid imbalance 4) Contractures
1
44.A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? 1) Take the medication 45 minutes before eating. 2) Expect diaphoresis as a side effect of the neostigmine. 3) If a medication dose is missed, wait until the next scheduled dose to take the medication. 4) Treat nasal rhinitis with an over-the-counter antihistamine.
1
48.A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? 1) Hypotension 2) Polyphagia 3) Hyperglycemia 4) Bradycardia
1
5. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? 1) Shivering 2) Infection 3) Burns 4) Hypervolemia
1
58.A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take? 1) Fully recollapse the reservoir after emptying it. 2) Empty the reservoir once per day. 3) Replace the drainage plug after releasing hand pressure on the device. 4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
1
7. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? 1) Cover the client's wound with a moist, sterile dressing. 2) Have the client lie supine with knees flexed. 3) Check the client's vital signs. 4) Inform the client about the need to return to surgery.
1
73.A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take? 1) Attempt to determine what the client was looking for. 2) Explain the client's Alzheimer's diagnosis to the frightened client. 3) Reprimand the client for invading the other client's privacy. 4) Ask the client to apologize for his behavior.
1
74.A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take? 1) Check pedal pulses every 15 min. 2) Perform passive range-of-motion for the affected extremity. 3) Remind the client not to turn from side to side. 4) Keep the client in high-Fowler's position for 6 hr.
1
84.A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds? 1) Expiratory wheeze 2) Pleural friction rub 3) Fine rales 4) Rhonchi
1
87.A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect? 1) Denial 2) Bargaining 3) Acceptance 4) Anger
1
9. A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? 1) Avoid bending at the waist. 2) Remove the eye shield at bedtime. 3) Limit the use of laxatives if constipated. 4) Seeing flashes of light is an expected finding following extraction.
1
95.A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects? 1) Reducing anxiety 2) Increasing blood pressure 3) Increasing coughing 4) Increasing the client's respiratory rate
1
96.A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report? 1) Frequent mood changes 2) Constipation 3) Sensitivity to cold 4) Weight gain
1
: 67.Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? 1) "Do you sleep well at night?" 2) "Have you been experiencing chills?" 3) "Have you experienced increased hair growth?" 4) "When did you begin your menses?"
1
38. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) 1) Encourage fluid intake. 2) Monitor the puncture site for hematoma. 3) Insert a urinary catheter. 4) Elevate the client's head of bed. 5) Apply a cervical collar to the client.
1 2
33.A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) 1) Buffalo hump 2) Purple striations 3) Moon face 4) Tremors 5) Obese extremities
1 2 3
13.A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations 5) Bradycardia
1 2 3 4
99.A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.) 1) Edema 2) Erythema 3) Tophi 4) Tight skin 5) Symmetrical joint pain
1 2 3 4
62.A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) 1) Decreasing anxiety 2) Controlling emesis 3) Relaxing skeletal muscles 4) Preventing surgical site infections 5) Reducing the amount of narcotics needed for pain relief
1 2 5
2. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? 1) Provide humidified oxygen. 2) Perform chest physiotherapy prior to suctioning. 3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway. 4) Hyperventilate the client with 100% oxygen before suctioning the airway..
1) Provide humidified oxygen.
1. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? 1) Take temperature once a day. 2) Wash the armpits and genitals with a gentle cleanser daily. 3) Change the litter boxes while wearing gloves. 4) Wash dishes in warm water.
1) Take temperature once a day
101.A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority? 1) Review stress factors that can cause disease exacerbation. 2) Evaluate fluid and electrolyte levels. 3) Provide emotional support. 4) Promote physical mobility.
2
105.A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first? 1) Obtain vital signs. 2) Stop the transfusion. 3) Notify the registered nurse. 4) Administer diphenhydramine.
2
109.A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a prescription for lorazepam preoperatively. Which of the following statements by the client should indicate to the nurse that the medication has been effective? 1) "My mouth is very dry." 2) "I feel very sleepy." 3) "I am not hungry any longer." 4) "My leg feels numb."
2
112.A nurse is assisting with teaching a client who has a history of smoking about recognizing early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report which of the following manifestations of laryngeal cancer? 1) Aphagia 2) Hoarseness 3) Tinnitus 4) Epistaxis
2
121.A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take? 1) Weigh the client weekly. 2) Irrigate the catheter as prescribed. 3) Instruct the client to report an urge to urinate. 4) Instruct the client to bear down as if to have a bowel movement every hour
2
123.A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Decreased pedal pulses 2) Hypertension 3) Peripheral edema 4) Diarrhea
2
130.A nurse is caring for a client who has second- and third-degree burns and a prescription for a high-calorie, high-protein diet. Which of the following menu choices should the nurse recommend? 1) ½ cup whole-grain pasta with tomato sauce and pears 2) Turkey and cheese sandwich with scalloped potatoes 3) ½ cup black beans with a brownie 4) Roast beef with romaine lettuce salad
2
131.A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram. Which of the following should the nurse include in the teaching? 1) Omit your daily dose of aspirin. 2) Take a laxative the evening before the procedure. 3) Expect to be drowsy for 24 hr following the procedure. 4) You will feel cold chills after the dye has been injected
2
20.A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? 1) Position the client supine while in bed. 2) Change the nasal drip pad as needed. 3) Encourage frequent brushing of teeth. 4) Encourage the client to cough every 2 hr following surgery.
2
25.A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? 1) Loosen the knots on the ropes if the client is experiencing pain. 2) Ensure the client's weights are hanging freely from the bed. 3) Check the client's bony prominences every 12 hr. 4) Cleanse the client's pin sites with povidone-iodine.
2
38.A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? 1) Notify the provider. 2) Verify that the suction regulator is on. 3) Continue to monitor the client because this is an expected finding. 4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
2
49.A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make? 1) Metabolic acidosis 2) Respiratory acidosis 3) Metabolic alkalosis 4) Respiratory alkalosis
2
55.A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? 1) Establish IV access. 2) Feel for a carotid pulse. 3) Establish an open airway. 4) Auscultate for breath sounds.
2
56.A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? 1) "Why have you changed your mind about the surgery?" 2) "Bypass surgery must be very frightening for you." 3) "Your provider would not have scheduled the surgery unless you needed it." 4) "I will call your doctor and have him discuss your surgery with you."
2
57.A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take? 1) Walk the client back to bed immediately and get the client a bedpan. 2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair. 3) Warn the client she might have to be restrained if she gets up without assistance. 4) Keep the bathroom door open to ensure the client is okay.
2
59.A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will not eat fried foods." 2) "I will abstain from sexual intercourse." 3) "I will refrain from international travel." 4) "I will not order a salad in a restaurant."
2
61.A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of the following manifestations should the nurse monitor? 1) Hypernatremia 2) Hypotension 3) Bradycardia 4) Hypokalemia
2
66.A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer? 1) Exposure to environmental pollutants 2) Sun exposure. 3) History of viral illness 4) Scars from a severe burn
2
68.A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching? 1) Cottage cheese 2) Fresh berries 3) Bran cereal 4) Skim milk
2
71.A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider? 1) Increase in serum glucose 2) Increase in serum creatinine 3) Decrease in white blood cell count 4) Decrease in platelets
2
78.A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching? 1) Temporary, reversible loss of brain function 2) Forgetfulness gradually progressing to disorientation 3) Sleeping more during the day than nighttime 4) Hyper vigilant behaviors
2
79.A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan? 1) Limit fluid intake.. 2) Monitor client's cardinal fields of vision. 3) Encourage ambulation. 4) Ensure the room is brightly lit
2
8. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? 1) Cool, clammy skin. 2) Hyperventilation 3) Increased blood pressure 4) Bradycardia
2
80.A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan? 1) Apply ice to the extremity 2) Monitor platelet levels 3) Restrict oral fluids 4) Administer vasodilating medications
2
83.A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client? 1) "I took a laxative yesterday." 2) "I took my metformin before breakfast." 3) "I haven't had anything to eat or drink since last night." 4) "The last time I voided it was painful."
2
86.A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure? 1) Prone with arms raised over the head. 2) Sitting, leaning forward over the bedside table. 3) High Fowler's position 4) Side-lying with knees drawn up to the chest.
2
94.A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? 1) Observing for facial asymmetry 2) Checking pupillary responses to light 3) Eliciting the gag reflex 4) Testing visual acuity
2
98.A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.) 1) Polyuria 2) Blurry vision 3) Tachycardia 4) Polydipsia 5) Sweating
2 3 5
3. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? 1) Rub the client's feet briskly for several minutes. 2) Obtain a pair of slipper socks for the client. 3) Increase the client's oral fluid intake. 4) Place a moist heating pad under the client's feet.
2) Obtain a pair of slipper socks for the client.
10.A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? 1) Suggest that the client rests before eating the meal. 2) Request a dietary consult. 3) Check the client's vital signs. 4) Request an order for an antiemetic
3
103.A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will take this medication until my BUN returns to normal." 2) "This medication will help my new kidney make adequate urine." 3) "I will need to take this medication for the rest of my life." 4) "This medication will boost my immune system."
3
104.A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication? 1) Improved speech patterns 2) Increased bladder function. 3) Decreased tremors 4) Diminished drooling
3
110.A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions? 1) Xerostomia 2) Gingivitis 3) Candidiasis 4) Halitosis
3
116.A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first? 1) Offer the client apple juice. 2) Elevate the client's head of bed. 3) Auscultate the client's abdomen. 4) Order a lunch tray for the client.
3
118.A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax? 1) Inspiratory stridor 2) Expiratory wheeze 3) Absence of breath sounds 4) Coarse crackles
3
128.A nurse in a provider's office is collecting data for a 45-year-old client who is having manifestations associated with perimenopause. Which of the following findings should the nurse expect? 1) Report of urinary retention 2) Elevated blood pressure above 140/90 3) Report of dryness with vaginal intercourse 4) Elevated body temperature above 37.8° C (100° F)
3
129.A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times? 1) On the same day every month 2) Prior to the beginning of menses 3) Three to seven days after menses stops 4) On the second day of menstruation
3
132.A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease? 1) "The pain is worse after I eat a meal high in fat." 2) "My pain is relieved by having a bowel movement." 3) "I feel so much better after eating." 4) "The pain radiates down to my lower back."
3
133.A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the following interventions should the nurse identify as the priority? 1) Promote the client's expression of feelings about loss of self-care ability. 2) Encourage the client to recall positive life events. 3) Schedule pain medication on a routine basis. 4) Suggest ways the client can continue interacting with social contacts.
3
134.A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching? 1) "When my vision improves, I will be able to stop taking the eye drops." 2) "If I forget to take my eye drops, I should wait until the next time they are due." 3) "I should call the clinic before taking any over-the-counter medications." 4) "Every two years I will need to have my vision checked by an eye doctor."
3
15.A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? 1) Monitor for elevated blood pressure. 2) Provide analgesia for headaches. 3) Prevent bladder distention. 4) Elevate the client's head.
3
21.A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? 1) To provide analgesia 2) To reduce inflammation 3) To prevent blood clotting 4) To prevent fever
3
23.A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? 1) Weight loss of 3% of total body weight. 2) Blood glucose 150 mg/dL. 3) Potassium 2.5 mEq/L 4) Urine specific gravity 1.035
3
28.A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? 1) Apply topical antifungal agents. 2) Apply fresh ice packs every 4 hr. 3) Wash daily with an antibacterial soap. 4) Keep draining lesions uncovered to air dry
3
32.A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? 1) Measure abdominal girth daily. 2) Use sterile water to irrigate the nasogastric tube.. 3) Maintain the client in Fowler's position. 4) Moisten the client's lips with lemon-glycerin swabs.
3
34.A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? 1) Provide a diet high in protein. 2) Provide ibuprofen for retroperitoneal discomfort. 3) Monitor intake and output hourly 4) Encourage the client to consume at least 2 L of fluid daily
3
35.A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? 1) "A flexible tube is introduced through the nose during the procedure." 2) "During the procedure you are in a sitting position." 3) "You will remain NPO for 8 hours before the procedure." 4) "You will be awake while the procedure is performed."
3
36.A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? 1) Aura phase 2) Presence of automatisms 3) Postictal phase 4) Presence of absence seizures
3
37.A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make? 1) "The pain results from lying in one position too long during surgery." 2) "The pain occurs as a residual pain from cholecystitis." 3) "The pain will dissipate if you ambulate frequently." 4) "The pain is caused from the nitrous dioxide injected into the abdomen."
3
4. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? 1) Emesis of 100 mL 2) Oral temperature of 37.5° C (99.5° F) 3) Thick, red-colored urine 4) Pain level of 4 on a 0 to 10 rating scale
3
42.A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take? 1) Instruct the client to tilt her head back when she swallows. 2) Place food on the left side of the client's mouth. 3) Add thickener to fluids. 4) Serve food at room temperature.
3
47.A nurse is assisting with planning care for a client who is recovering from a lefthemispheric stroke. Which of the following interventions should the nurse include in the plan? 1) Control impulsive behavior. 2) Compensate for left visual field deficits. 3) Re-establish communication. 4) Improve left-side motor function.
3
52.A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? 1) Decreased perfusion 2) Infection 3) Granulation tissue 4) An inflammatory response
3
60.A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? 1) Rest in a supine position. 2) Consume a low-protein diet. 3) Breathe in through her nose and out through pursed lips. 4) Limit fluid intake throughout the day.
3
63.A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? 1) Vitamin D 2) Vitamin A 3) Iron 4) Niacin
3
75.A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza? 1) Individuals at high risk should receive the live influenza vaccine. 2) Immunization for influenza should be repeated every 10 years. 3) The composition of the influenza vaccine changes yearly. 4) The influenza vaccine is necessary only for clients who have never had influenza.
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76.A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take? 1) Tell the client to have a family member call the provider to ask what options he plans to recommend. 2) Assure the client that the provider will tell him what is planned. 3) Help the client write down questions to ask his provider. 4) Provide the client with a pamphlet of information about cancer
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77.A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make? 1) "If you just sit quietly with your mother, I'm sure she will calm down." 2) "I'll talk with your mother and see if I can comfort her." 3) "It must be hard to see your mother so ill and upset." 4) "Your mother's crying seems to bother you more than it does her."
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82.A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus? 1) Serum sodium 145 mEq/L 2) Urine specific gravity 1.028 3) Urine output 650 mL/hr 4) Blood glucose 198 mg/dL
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85.A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take? 1) Remove the entire dressing at once. 2) Loosen the dressing by pulling the tape away from the wound. 3) Don clean gloves to remove the dressing. 4) Open sterile supplies before removing the dressing.
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89.A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses? 1) Neck vein distention 2) Blood pressure 3) Body weight 4) Abdominal girth
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90.A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations? 1) Urticaria 2) Muscle pain 3) Hypotension 4) Distended neck veins
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93.A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make? 1) "You shouldn't feel any pain since the local area is anesthetized." 2) "Most clients report more discomfort from the preparation than from the procedure itself." 3) "You may feel some cramping during the procedure." 4) "Don't worry; you won't remember anything about the procedure due to the effects of the medication."
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11.A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? 1) Sanguineous 2) Serous 3) Serosanguineous 4) Purulent
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113.A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following laboratory values should the nurse review to determine the client's renal function? 1) Antinuclear antibody 2) C-reactive protein 3) Erythrocyte sedimentation rate 4) Serum creatinine
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117.A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse? 1) The wound is tender to touch. 2) The wound has pink, shiny tissue with a granular appearance. 3) The wound has serosanguineous drainage. 4) The wound has a halo of erythema on the surrounding skin.
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119.A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? 1) Frothy sputum 2) Dyspnea 3) Orthopnea 4) Peripheral edema
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125.A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk to the client? 1) Hypothermia 2) Hyponatremia 3) Fluid imbalance 4) Airway obstruction
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14.A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first? 1) Take the client's temperature. 2) Place a dressing under the client's nose. 3) Notify the charge nurse. 4) Test the drainage for glucose.
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16.A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? 1) Hot flashes 2) Recurrent urinary tract infections 3) Blood in the stool 4) Abnormal vaginal bleeding
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24.A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching? 1) "I should increase my intake of protein and vitamin C." 2) "I will no longer have menstrual periods." 3) "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience discomfort." 4) "I will take a tub bath instead of a shower."
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29.A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? 1) Empty the pouch immediately after meals. 2) Change the entire appliance once a day. 3) Limit fluid intake. 4) Avoid medications in capsule or enteric form.
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30.A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? 1) "An escharotomy surgically removes dead tissue." 2) "A cannula will be inserted into the bone to infuse fluids and antibiotics." 3) "A piece of skin will be removed and grafted over the burned area." 4) "Large incisions will be made in the burned tissue to improve circulation."
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40.A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? 1) Relieve the client's pain. 2) Check the client's pressure points for redness. 3) Provide oral hygiene. 4) Prevent aspiration.
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41.A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? 1) A dry raised rash 2) Excessive salivation 3) Periorbital edema 4) Hardened skin
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45.A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? 1) Notify the provider. 2) Administer a prescribed analgesic. 3) Offer oral fluids. 4) Determine the patency of the tubing.
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46.A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? 1) "You must be very worried about what the biopsy will show." 2) "You'll be asleep for the whole biopsy procedure and won't be aware of what's happening." 3) "Your provider scheduled this, so she will want to know you still have questions about the procedure." 4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible."
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50.A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching? 1) "I will avoid crossing my legs at the knees." 2) "I will use a thermometer to check the temperature of my bath water." 3) "I will not go barefoot." 4) "I will wear stockings with elastic tops."
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51.A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? 1) Turn the water on and ask the client to test the temperature. 2) Obtain assistance to place mitten restraints on the client. 3) Firmly tell the client that good hygiene is important. 4) Calmly ask the client if he would like to listen to some music
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53.A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3 . Which of the following food items brought by the family should the nurse prohibit from being given to the client? 1) Baked chicken 2) Bagels 3) A factory-sealed box of chocolates 4) Fresh fruit basket
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54.A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan? 1) Perform the client's personal care activities for her. 2) Limit the client's fluid intake. 3) Monitor the Homan's sign. 4) Maintain abduction of the right hip.
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6. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will carry a complex carbohydrate snack with me when I exercise." 2) "I should exercise first thing in the morning before eating breakfast." 3) "I should avoid injecting insulin into my thigh if I am going to go running." 4) "I will not exercise if my urine is positive for ketones
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64.A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? 1) Malnourishment related to NPO status and dysphagia 2) Impaired verbal communication related to the tracheostomy 3) High risk for infection related to surgical incisions 4) Ineffective airway clearance related to thick, copious secretions
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65.A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? 1) Walk with leg braces and crutches. 2) Drive an electric wheelchair with a hand-control device. 3) Drive an electric wheelchair equipped with a chin-control device. 4) Propel a wheelchair equipped with knobs on the wheels.
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69.A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Polyuria 2) Battle's sign 3) Nuchal rigidity 4) Lethargy
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70.A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? 1) "Tonometry is performed to evaluate peripheral vision." 2) "This test will diagnose the type of your glaucoma." 3) "Tonometry will allow inspection of the optic disc for signs of degeneration." 4) "This test will measure the intraocular pressure of the eye."
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72. A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? 1) Apical pulse rate different than the radial pulse rate 2) Increase in heart rate by 20% when standing 3) Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position 4) Drop in systolic BP more than 10 mm Hg on inspiration
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81.A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client? 1) Tuberculin skin test 2) Sputum culture for acid fast bacillus (AFB) 3) Bacille Calmette-Guérin (bCG) vaccine 4) Chest x-ray
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88.A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed-suction drains in place. Which of the following interventions should the nurse include in the plan? 1) Irrigate the nasogastric tube with tap water. 2) Mark abdominal girth once daily. 3) Ambulate the client twice daily. 4) Place the client in a high Fowler's position.
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91.A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions? 1) A continuous seizure state in which seizures occur in rapid succession 2) A sensory warning that a seizure is imminent 3) A period of sleepiness following the seizure during which arousal is difficult 4) A brief loss of consciousness accompanied by staring
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92.A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider? 1) "The bright light in this room is really bothering me." 2) "My eye really itches, but I'm trying not to rub it." 3) "It's really hard to see with a patch on one eye." 4) "I need something for the horrible pain in my eye."
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97.A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? 1) Serosanguineous drainage 2) Mild erythema 3) Warmth 4) Fever
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120.A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take? 1) Advise the client to lie down after meals. 2) Instruct the client to restrict food intake prior to treatment. 3) Provide the client with an antiemetic 2 hr prior to the chemotherapy. 4) Encourage the client to drink a carbonated beverage 1 hr before meals.
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