ATI Questions 2

A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take? (SATA). a. Apple pressure to the nares b. Place ice to the bridge of the client's nose c. Instruct the client to blow his nose d. Tilt the client's head backward e. Move the client into high-fowler's position

A B E

Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)? a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses c. Helping the patient to ambulate to the bathroom to void d. Telling the patient that he will be sleepy from the general anesthesia e. Teaching the patient about the risks of the radioactive isotope injection

A B

A patient has a severe blockage in his right coronary artery. Which heart structures are most likely to be affected by this blockage (select all that apply)? a. AV node b. Left ventricle c. Coronary sinus d. Right ventricle e. Pulmonic valve

A, B, D

A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? (Select all that apply.) a. "You'll have to lie flat for several hours after the procedure." b. "You'll receive medication to relax you before the procedure." c. "You'll feel a cool sensation after the injection of the dye." d. "You'll have to keep your leg straight after the procedure." e. "You'll have to limit the amount of fluid you drink for the first 24 hr."

A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." D. "You'll have to keep your leg straight after the procedure."---Depending on the provider's prescription, the client should remain flat or with the head of the bed elevated to no more than 30° for 2 to 6 hours after the procedure. The amount of time depends on the type of closure device the provider uses. The client will receive a mild sedative for relaxation and comfort prior to the procedure. A soft knee brace can help keep the client from bending the knee after the procedure.

A nurse is caring for a client who is undergoing conservative treatment for deep-vein thrombosis. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make? A. "Your body has a process called fibrinolysis that will eventually dissolve the clot." B. "Your body has a mechanism that will keep the clot stable in its present location." C. "The clot will break into tiny fragments and float harmlessly in your bloodstream." D. "Treatment with heparin will dissolve the clot and keep other clots from forming."

A. "Your body has a process called fibrinolysis that will eventually dissolve the clot."--- Fibrinolysis is a process that breaks down a clot over time in the body. This process is a treatment option for clots that are not immediately life-threatening.

A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0-10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take? a. Admin another nitroglycerin tablet b. Initiate a peripheral IV c. Call the Rapid Response Team d. Obtain an ECG

A. Admin. Another nitroglycerin tablet--- Admin guideline for sublingual nitroglycerin indicate that it is appropriate to admin another tablet 5 min after the first one if the client is still reporting pain

A nurse is administering subcutaneous heparin to a client who is at risk for deep vein thrombosis. Which of the following actions should the nurse take? a. Administer the medication into the client's abdomen b. Inject the medication into a muscle c. Massage the site after administering the medication d. Use a 22-gauge needle to administer the medication

A. Administer the medication into the client's abdomen---The heparin should be administered into the client's abdomen.

A nurse is assessing a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (Select all that apply.) a. Hardening along the blood vessel b. Absence of a peripheral pulse c. Tenderness in the calf d. Cool skin on the leg e. Increased leg circumference

A. Hardening along the blood vessel C. Tenderness in the calf E. Increased leg circumference--- Deep-vein thrombosis can cause hardening along the affected blood vessel and prominence of superficial veins, pain or tenderness in the calf, and an increase in the circumference of the leg due to swelling.

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? a. Hypokalemia b. Hypophosphatemia c. Hypercalcemia d. Hypermagnesemia

A. Hypokalemia---- Furosemide can cause the loss of potassium, sodium, calcium, and magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats.

A nurse is preparing to administer a sublingual nitroglycerin tablet to a client who is reporting chest pain. For which of the following adverse effects should the nurse monitor after giving this medication? a. Hypotension b. Myalgia c. Diarrhea d. Ototoxicity

A. Hypotension---Nitroglycerin is a coronary vasodilator and antianginal agent. A major adverse effect of this medication is hypotension; therefore, blood pressure and pulse must be monitored before and after administration.

A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of MI? (Select all that apply.) a. Nausea and vomiting b. Diaphoresis and dizziness c. Chest and left arm pain that subsides with rest d. Anxiety and feelings of doom e. Bounding pulse and bradypnea

A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom--- Nausea, vomiting, epigastric distress, diaphoresis (sweating), dizziness, fatigue, anxiety, and feelings of doom and fear are common manifestations of MI.

A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations? a. Necrosis b. Hypokalemia c. Hypomagnesemia d. Insufficiency

A. Necrosis---- ST-segment elevation during an acute myocardial infarction indicates necrosis. This ECG change reflects a clot at the site of injury. Therefore, the client requires immediate revascularization of the artery.

A nurse is caring for an older adult client who had an acute myocardial infarction (MI). When assessing this client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age-related factors? a. Peripheral vascular resistance increases. b. The sensitivity of blood pressure-adjusting baroreceptors increases. c. Blood is hypercoagulable and clots more quickly. d. Cardiac medications are less effective.

A. Peripheral vascular resistance increases.----Older adult clients are more prone to complications from poor tissue perfusion following an acute MI because peripheral vascular resistance increases with aging. This results from calcification and loss of elasticity of the blood vessels.

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? a. Potassium 2.8 mEq/L b. Digoxin level 0.7 ng/mL c. Hemoglobin 9.8 g/dL d. Calcium 8.0 mg

A. Potassium 2.8 mEq/L---A flattened T wave or the development of U waves is indicative of a low potassium level.

A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion? a. Ventricular dysrhythmias b. Appearance of Q waves c. Elevated ST segments d. Recurrence of chest pain

A. Ventricular dysrhythmias---The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery.

A nurse at a provider's office receives a phone call from a client who reports nausea and unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse? a. Tell the client to take an antacid b. Instruct the client to call 911 c. Tell the client to take another nitroglycerin tablet in 15 min d. Advise the client to come to office

B) Instruct the client to call 911-- The nurse should instruct the client to call 911 for transportaition to the emergency department because the client is having unstable angina or an acute MI.

After teaching about ways to decrease risk factors for CAD, the nurse recognizes that further instruction is needed when the patient says a. "I can keep my blood pressure normal with medication." b. "I would like to add weight lifting to my exercise program." c. "I can change my diet to decrease my intake of saturated fats." d. "I will change my lifestyle to reduce activities that increase my stress."

B

The nurse is caring for a patient who is 2 days post MI. The patient reports that she is experiencing chest pain when she takes a deep breath. Which action would be a priority? a. Notify the provider STAT and obtain a 12-lead ECG. b. Obtain vital signs and auscultate for a pericardial friction rub. c. Apply high-flow O2 by face mask and auscultate breath sounds. d. Medicate the patient with as-needed analgesic and reevaluate in 30 minutes.

B

Erectile dysfunction drugs such as sildenafil (Viagra) are contraindicated in clients taking nitrates for angina. What is the primary concern with concurrent administration of these drugs? a. They contain nitrates, resulting in an overdose. b. They decrease blood pressure and may result in prolonged and severe hypotension when combined with nitrates. c. They will adequately treat the patient's angina as well as erectile dysfunction. d. They will increase the possibility of nitrate tolerance developing and should be avoided unless other drugs can be used.

B) They decrease blood pressure and may result in prolonged and severe hypotension when combined with nitrates. Erectile dysfunction drugs such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) decrease BP. When combined with nitrates, severe and prolonged hypotension may result.

A nurse is providing teaching for a client who has hypertension and a prescription change from metoprolol/hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching? a. "Now I will not have to diet to lose weight." b. "With the new medication, I should experience fewer side effects." c. "I will not have to do anything different because it is the same medication." d. "The extra letters after the name of medication means it is a stronger dose."

B. "With the new medication, I should experience fewer side effects."--- The client has states an understanding of the purpose of the addition of the hydrochlorothiazide to the metoprolol dosage. When used in combo with thiazide diuretic, a lower dose of the beta-blocker can be used. The benefit is there are fewer side effects when beta-blockers (and other antihypertensives) are used in lower dosages.

A nurse is reviewing the medical record of a client who has hypertension and a new prescription for metoprolol. Which of the following findings should the nurse investigate further? a. Diet-controlled type 2 diabetes mellitus b. A hx of left-sided heart failure c. A concurrent prescription for tadalafil d. Recently treated bilateral pneumonia

B. A hx of left-sided heart failure--- The nurse should further investigate the client's hx of heart failure. Although metoprolol can be used to treat heart failure, it can also cause heart failure, so this medication should be used with great caution with a client who has a hx of heart failure. The nurse should teach the client to watch for signs of increasing left-sided heart failure, such as shortness of breath & wt gain indicating fluid retention, & report these findings to the provider.

A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (Select all that apply.) a. Hypothyroidism b. Hypertension c. Diabetes mellitus d. Hyperlipidemia e. Tobacco smoking

B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking--- A client who has hypertension, diabetes mellitus, hyperlipidemia, or a history of smoking tobacco is at risk for coronary artery disease (CAD). Hypertension and hyperlipidemia can be controlled by diet and exercise, along with medication if needed. Diabetes can cause damage to large and small blood vessels, which leads to poor perfusion, cell death, and organ damage. Diabetes mellitus can be managed by monitoring glucose levels and implementing diet and exercise recommendations. Cholesterol levels, such as total HDL and LDL levels, should be monitored since elevated total serum cholesterol levels increase the risk of a myocardial infarction. Finally, smoking accelerates the rate of the narrowing of the coronary arteries and increases the risk of clot formation. Smoking cessation classes or other forms of treatment can be offered to help the client quit smoking.

A nurse is caring for a client who has unstable angina. The nurse should anticipate a prescription from the provider for which of the following medications? a. Epinephrine b. Nitroglycerin c. Lidocaine d. Atropine

B. Nitroglycerin--- The nurse should anticipate a prescription for nitroglycerin, which is indicated for a client who has unstable angina. Nitroglycerin is an organic nitrate and a vasodilator that acts by relaxing or preventing spasms in the coronary arteries, thereby decreasing the oxygen demand of the heart along with ventricular filling.

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEw/L. Which of the following actions should the nurse take? a. Suggest that the client use a salt substitute b. Obtain a 12-lead ECG c. Advise the client to add citrus juices and bananas to her diet d. Obtain a blood sample for a serum sodium level

B. Obtain a 12-lead ECG--- The pt is at risk for dysrhythmias as well as cardiac arrest. The nurse should obtain a 12-lead ECG to monitor for cardiac changes

A nurse is establishing health promotion goals for a female client who smokes cigarettes. Has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? a. The client will list foods that are high in calcium, which should be avoided b. The client will walk for 30 min/5 days a week c. The client will increase calorie intake by 200 cal per day d. The client will replace cigarettes with smokeless tobacco products

B. The client will walk for 30 min/5 days a week--- CDC recommends include engaging in a moderate exercise, such as walking, for a total of 150 min each week.

A patient is recovering from an uncomplicated MI. Which rehabilitation guideline is a priority to include in the teaching plan? a. Refrain from sexual activity for a minimum of 3 weeks. b. Plan a diet program that aims for a 1- to 2-lb weight loss per week. c. Begin an exercise program that aims for at least 5 30-minute sessions per week. d. Consider the use of erectile agents and prophylactic NTG before engaging in sexual activity.

C

A nurse is reviewing the laboratory values of a client who had a MI 3 hr ago. The nurse should expect which of the following lab values to be elevated? a. Aspartate aminotransferase (AST) b. Unconjugated bilirubin c. Troponin I d. Serum amylase

C) Troponin I--- Cardiac troponin I & cardiac troponin T are biochemical markers that are specific to myocardial cell injury. A client who has myocardial cell damage can have elevated troponin levels within 2-3 hr. Cardiac troponin I levels can peak in 10-24 hr & stay elevated for 7-10 days. Cardiac troponin T levels can peak within 10-24 hr stay elevated for 10-14 days.

A home health nurse is performing an assessment on a client who is 1 week postoperative following a total knee replacement. Which of the following statements by the client indicates an understanding of the teaching? a. "I will discontinue the blood thinner my doctor prescribed once I am at home." b. "I will keep a pillow under my knee when I am in bed." c. "I plan to use a walker to help me get around." d. "I will discontinue using the CPM machine when I get home."

C. "I plan to use a walker to help me get around."--- The nurse should identify that the client will receive a prescription for a walker, cane, or crutches to promote ambulation following a total knee replacement.

A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? a. Pitting edema b. Areas of reddish-brown pigmentation c. Dry, pale skin with minimal body hair d. Sunburned appearance with desquamation

C. Dry, pale skin with minimal body hair--- A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.

A nurse is preparing to administer digoxin to a client. Which of the following findings should the nurse identify as a contraindication to the client receiving this medication? a. Blood pressure 180/70 mmHg b. Oxygen saturation rate 94% c. Heart rate 51/min d. Respiratory rate 21/min

C. Heart rate 51/min---- The nurse should identify that if the client's heart rate is less than 60/min, the medication should be withheld, and the provider should be notified.

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? a. Attach the leads for a 12-lead ECG b. Obtain a blood sample c. Initiate O2 therapy d. Insert the IV catheter

C. Initiate O2 therapy--- The greatest risk to the client's safety is myocardial ischemia and cellular death; therefore, the priority action the nurse should take is to admin. O2 to help minimize this possibility.

A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the following findings should the nurse identify as an associated manifestation of an MI? a. Headache b. Hemoptysis c. Nausea d. Diarrhea

C. Nausea---Nausea is an associated manifestation of MI. Manifestations of MI include chest pain and pain in the jaw, shoulder, or abdomen.

A nurse is caring for a client who reports crushing chest pain. The nurse reviews the client's ECG results and notes ST changes. Which of the following medications should the nurse administer? a. Simvastatin b. Furosemide c. Nitroglycerin d. Sildenafil

C. Nitroglycerin---The nurse should identify the need to administer nitroglycerin, which is used to treat angina. Nitroglycerin acts directly on vascular smooth muscle to promote vasodilation.

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a MI? a. Check the client's BP b. Auscultate heart tones c. Perform a 12-lead ECG d. Determine if pain radiates to the left arm

C. Performs a 12-lead ECG--- The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a MI.

A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI? a. Dyspnea b. Pain in the shoulder and left arm c. Substernal chest pain d. Palpitations

C. Substernal chest pain---Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation.

A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction? a. Sudden hemoptysis b. Acute diarrhea c. Frontal headache d. Acute confusion

D. Acute confusion--- Acute confusion is a manifestation of myocardial infarction in clients age 65 or older. Other manifestations can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue.

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? a. Administer aspirin b. Tilt the child's head back and apply pressure c. Have the child lie down and rest d. Apply continuous pressure to the lower part of the child's nose

D. Apply continuous pressure to the lower part of the child's nose----With the child sitting up and breathing through the mouth, the nurse should apply continuous pressure with the thumb and forefinger to the soft lower area of the nose for 10 minutes. Most bleeding from the nose stops within this period.

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? a. Have the client gently blow clots from the nose every 5 min b. Instruct the client to sit with his head hyperextended c. Apply ice compresses to the back of the client's neck d. Apply lateral pressure to the client's nose for 10 min

D. Apply lateral pressure to the client's nose for 10 min----The nurse should apply direct, lateral pressure to the nose for 10 minutes to control epistaxis. If after 10 minutes the epistaxis continues, the client might require nasal packing or other interventions.

A nurse is caring for a client who has congestive heart failure and is taking digoxin. The client reports nausea and refuses to eat breakfast. Which of the following actions should the nurse take first? a. Encourage the client to eat the toast on the breakfast tray b. Administer an antiemetic c. Inform the client's provider d. Check the client's apical pulse

D. Check the client's apical pulse---- Nausea, anorexia, fatigue, visual effects, and cardiac dysrhythmias (often caused by a slow pulse rate) are possible findings in digoxin toxicity. Caring for this client requires the application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider about a change in the client's status, the nurse must first collect adequate data from the client. Assessing will provide the nurse with the knowledge to make an appropriate decision.

A nurse is caring for a client who has a vitamin K deficiency. Which of the following manifestations should the nurse expect? a. Irregular bone formation b. Abnormal movements c. Blurred vision d. Excessive bruising

D. Excessive bruising--- The nurse should identify that excessive bruising can indicate bleeding under the skin. Vitamin K is needed by clotting factors to coagulate the blood. Therefore, a client who has a deficiency in vitamin K is at risk for excessive bruising and bleeding.

A nurse is applying antiembolic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? a. Roll the stocking partially down if too long b. Remove the stocking once per day c. Bunch and pull the stocking halfway up the calf d. turn the stocking inside out up to the heel before applying

D. Turn the stocking inside out up to the heel before applying--- The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause fewer constrictive wrinkles.

A nurse is planning postoperative education for a client who will undergo a radial neck dissection for cancer of the larynx. The nurse should include which of the following topics? (select all that apply) a. NPO status b. alterative methods of communication c. endotracheal intubation d. changes in body image e. swallowing exercises

a. b. d. e.

A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should nurse include? a. "You will need to apply a cold pack to the site 3 times a day." b. "Your provider might ask you to walk frequently to increase circulation to the area." c. "You will need to limit your consumption of high-protein foods." d. "Your provider might prescribe a central catheter line for a long-term antibiotic therapy."

d. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."

A charge nurse is observing a newly licensed nurse administer an IV medication to a client who has an implanted venous access port. Which of the following observations requires intervention by the charge nurse? a. a dressing is not applied to the port after use b. a 22-gauge non coring needle is used to access the port c. blood return is noted prior to administering the medication d. a solution of 5 mL heparin 1,000 units/mL has prepared

d. a solution of 5 mL heparin 1,000 units/mL has been prepared

A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. Which of the following laboratory values is consistent with diabetic ketoacidosis? a. blood glucose 30 mg/dL b. negative urine ketones c. blood pH 7.38 d. bicarbonate level 12 mEq/L

d. bicarbonate level 12 mEq/L

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make? a. "A headache is an indication of an allergy to the medication" b. "A headache is an expected adverse effect of the medication" c. "A headache indicates tolerance to the medication" d. "A headache is likely due to the anxiety about the chest pain"

B. "A headache is an expected adverse effect of the medication"--- The vasodilation nitroglycerin induces increases blood flow to the head & typically results in a headache.

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous." Which of the following responses should the nurse offer? a. "You won't need the equipment for very long." b. "All of this equipment can be frightening." c. "Why does the equipment bother you?" d. "Let me tell you about what each machine does."

B. "All of this equipment can be frightening."---This statement is therapeutic because the nurse is reflecting the client's statement. The client is feeling fearful, and this response shows the nurse understands those feelings, which will encourage the client to communicate more.

A nurse is teaching a client about the proper placement of a nitroglycerin patch. Which of the following statements by the client indicates an understanding of the teaching? a. "I'll apply the patch over areas of my body with little fatty tissue." b. "I can place the patch on any area of my body without hair." c. "I'll put the patch on the same site as the previous patch." d. "I have to apply the patch directly over my heart."

B. "I can place the patch on any area of my body without hair."--- The nitroglycerin transdermal patch should be applied to skin that is free from hair because hair creates a physical barrier to absorption.

A nurse is providing discharge teaching for a client who had a left total hip arthroplasty. Which of the following client statements indicates the teaching was effective? a. "I should expect swelling of the affected leg for several weeks." b. "I should not cross my legs at the ankles or knees." c. "I will inspect my hip incision every other day for redness." d. "I can bend over at the hip to pick up objects."

B. "I should not cross my legs at the ankles or knees."---The nurse should instruct the client to avoid crossing the legs at the knees or ankles because this can result in the dislocation of the femoral head

A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? a. Absent pedal pulses b. Ankle swelling c. Hair loss d. Skin atrophy

B. Ankle swelling--- The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. Other manifestations can include brown pigmentations and cellulitis.

A nurse is preparing to administer nitroglycerin topical ointment to a client who has angina. Which of the following actions should the nurse take? a. Cover the applied ointment with cotton gauze b. Apply the ointment using a dose-measuring applicator c. Apply the ointment using the index finger d. Massage the ointment into the client's skin

B. Apply the ointment using a dose-measuring applicator---The nurse should apply the ointment using a dose-measuring applicator. This allows the nurse to measure the correct dose the client is to receive.

A nurse is providing discharge teaching to a client who has venous thrombosis and a prescription for warfarin. Which of the following instructions should the nurse include in the teaching? a. Take ibuprofen as needed for headaches or other minor pains b. Carry a medical alert ID card c. Report to the laboratory weekly to have blood drawn for aPTT d. Increase intake of dark green vegetables

B. Carry a medical alert ID card---A client who is taking warfarin is at increased risk for bleeding. In the case of an emergency, any medical personnel must be aware of the client's medication history.

A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? a. Cardiogenic shock b. Dysrhythmias c. Heart failure d. Pulmonary edema

B. Dysrhythmias---- According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately.

A nurse is caring for a client who has severely elevated blood pressure. Which of the following findings should the nurse identify as a manifestation of hypertension? a. Vertigo b. Epistaxis c. Exophthalmos d. Spondylolisthesis

B. Epistaxis---Epistaxis (a nosebleed) is a manifestation of elevated blood pressure. Hypertension is often asymptomatic, but when it is severely elevated, it can also cause headaches, dizziness, facial flushing, and fainting.

A nurse is admitting a client who is scheduled to undergo a cardiac catheterization. The client says, "My coworker died last week from a heart attack." Which of the following responses should the nurse offer? a. "Your provider will not let that happen because she knows how to treat your condition." b. "Do you think the same thing might happen to you?" c. "You appear to be feeling anxious." d. "Has anyone in your family had a heart attack?"

C. "You appear to be feeling anxious."---The nurse is sharing observations that will encourage the client to be more specific about these feelings.

A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? a. Temperature 37.5°C (99.5°F) b. Apical pulse rate 140/min c. BP 86/40 mmHg d. Respiratory rate 32/min

C. BP 86/40 mmHg---A BP of 86/40 mmHg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider.

A nurse is reviewing the medical record of a client who is receiving hydrochlorothiazide (HCTZ). The nurse should expect to find an improvement in which of the following conditions as a result of this medication? a. Gouty arthritis b. Dehydration c. Diabetes insipidus d. Hypokalemia

C. Diabetes insipidus--- A thiazide diuretic such as HCTZ is administered to treat diabetes insipidus. Diabetes insipidus is a condition in which there is an overproduction of urine. Thiazides reduce urine production by 30% to 50%.

A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? a. Infective endocarditis b. Pericarditis c. Ventricular dysrhythmias d. Pulmonary emboli

C. Ventricular dysrhythmias---- After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system.

A nurse is providing teaching for a client who has a new prescription for nitroglycerin administered through a transdermal patch. Which of the following client statements indicates an understanding of the teaching? a. "I need to wear the patch continuously for it to be effective." b. "I will stop using the patch immediately if it gives me a headache." c. "I should change the patch whenever I have chest pain." d. "I need to rotate the location of my patch every few days."

D. "I need to rotate the location of my patch every few days."---The nitroglycerin patch should be rotated to different hairless areas of the client's body every few days to avoid local skin irritation.

A nurse is providing discharge teaching to a client who has heart failure and a prescription for digoxin 0.125 mg PO daily and furosemide 20 mg PO daily. Which of the following statements by the client indicates an understanding of the teaching? a. "I know that blurred vision is expected to happen while I'm taking digoxin." b. "I will measure my urine output each day and document it in my diary." c. "I will skip a dose of my digoxin if my resting heart rate is below 72 beats per minute." d. "I will eat fruits and vegetables that have a high potassium content every day."

D. "I will eat fruits and vegetables that have a high potassium content every day."--- Hypokalemia is an adverse effect of diuretic therapy. Because the client is taking digoxin, it is important to maintain a potassium level between 3.5 to 5.0 mg/dL to avoid digoxin toxicity.

A nurse is teaching a 70-year-old client about risk factors for heart failure. The client has mild asthma, diabetes mellitus, and coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? a. "My diabetes will not increase my risk of heart failure." b. "My asthma makes it more likely for me to have heart failure." c. "My age does not increase my risk of heart failure." d. "My coronary artery disease is a risk factor for heart failure."

D. "My coronary artery disease is a risk factor for heart failure."---- Coronary artery disease is a primary risk factor for the development of heart failure. Other risk factors include hypertension, cardiomyopathy, tobacco use, family history, and hyperthyroidism.

A nurse is providing teaching to a client who has a new prescription for hydrochlorothiazide 50 mg PO daily to treat hypertension. Which of the following instructions should the nurse include in the teaching? a. "Take hydrochlorothiazide as needed for edema." b. "Check your weight once each week." c. "Take hydrochlorothiazide on an empty stomach." c. "Take hydrochlorothiazide in the morning."

D. "Take hydrochlorothiazide in the morning."---The client should take hydrochlorothiazide in the morning to allow for diuresis during the day and to prevent nocturia.

A nurse is providing teaching to a client who is scheduled to start taking hydrochlorothiazide for hypertension. The nurse instructs the client to eat foods that are rich in potassium. Which of the following statements by the client indicates an understanding of the teaching? a. "This medication will not work unless I have enough potassium." b. "Potassium will increase the therapeutic effect of my blood pressure medication." c. "Potassium will lower my blood pressure. d. "This medication can cause a loss of potassium."

D. "This medication can cause a loss of potassium."--- Hydrochlorothiazide can result in hypokalemia caused by excessive potassium excretion from the kidneys. The client should supplement his diet with potassium-rich foods to avoid the occurrence of hypokalemia. Foods that are high in potassium include bananas, raisins, baked potatoes, pumpkins, and milk.

A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? a. Chest pain is relieved soon after resting. b. Nitroglycerin relieves chest pain. c. Physical exertion does not precipitate chest pain. d. Chest pain lasts for longer than 15 min.

D. Chest pain lasts for longer than 15 min--- A client who has unstable angina will have chest pain lasting longer than 15 minutes. This is due to reduced blood flow in a coronary artery from atherosclerotic plaque and thrombus formation causing partial arterial obstruction or from an artery spasm.

A nurse is caring for a group of client on a medical-surgical unit. Which of the following disorders should the nurse identify as increasing the client's metabolic needs? (select all that apply) a. COPD b. hypothyroidism c. cancer d. Parkinson's disease e. major burns

a. c. d. e.

A nurse is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. Which of the following instructions should the nurse include? a. "Take this med before bedtime" b. "Monitor for leg cramps" c. "Avoid grapefruit juice" d. "Reduce intake of potassium-rich foods"

B. "Monitor for leg cramps"--- Hydrochlorothiazide can cause hypokalemia. The client should monitor for manifestations of hypokalemia, such as fatigue,tachycardia, leg cramps, & muscle weakness

A nurse is assessing a client who is experiencing chest pain. Which of the following medications should the nurse expect to administer to suppress the aggregation of platelets? a. Nitroglycerin b. Aspirin c. Morphine d.Metoprolol

B. Aspirin---Aspirin suppresses platelet aggregation, producing an immediate antithrombotic effect. The client should chew the first dose of aspirin to allow rapid absorption.

A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should indicate to the nurse the client is experiencing digoxin toxicity? a. Suppression of dysrhythmias b. Increased atrioventricular (AV) conduction c. Visual disturbances d. Weight gain

C. Visual disturbances----The nurse should recognize that nausea, vomiting, abdominal discomfort, fatigue, and visual disturbances are common manifestations that can indicate that the client is experiencing digoxin toxicity.

A nurse is teaching a client who has HIV about the early manifestations of AIDS. Which of the following statements should the nurse include in the teaching? a. "You can expect a persistent fever and swollen glands" b. "You can expect an elevated white blood count" c. "You can expect increased blood pressure and edema" d. "You can expect weight gain"

a. "You can expect a persistent fever and swollen glands"

A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? a. jaundice b. anorexia c. dark urine d. pale feces

b. anorexia anorexia is an early manifestation of a hepatitis A and is often severe. it is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product.

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? a. occipital b. temporal c. frontal d. limbic

c. frontal the nurse should identify that the posterior portion of the frontal lobe is responsible for the verbal expression of thought

A nurse is providing dietary teaching a client who has late-stage chronic kidney disease. Which of the following nutrients should the nurse instruct the client to increase in her diet? a. calcium b. phosphorus c. potassium d. sodium

a. calcium

A nurse is teaching a client who has chronic kidney disease. Which of the following instructions should the nurse include? a. limit fluid intake b. limit caloric intake c. eat a diet high in phosphorus d. eat a diet high in protein

a. limit fluid intake a client who has CKD should limit fluid intake to prevent hypervolemia

a nurse is caring for a client who has a prescription for acetaminophen 325 mg PO for an oral temperature above 38.4C. above what Faherenheit temperature should the nurse administer acetaminophen to the client?

101.1

a nurse is calculating a client's intake for a 12-hr shift. the client had dextrose 5% in 0.45% sodium chloride infusing at 125mL/hr, gentamicin 150mg in 100 mL at 1400, famotidine 20mg in 50 mL at 1000 & 1600, 250mL of blood over 2 hours, nd a nasogastric flush of 30 mL every 2 hours. what is the total intake in millimeters that the nurse should document for this client for this 12 your period?

2130

a nurse is monitoring a client's fluid intake. for breakfast, the client consumed 8 oz, 10 oz water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon (9.86mL), & 2 biscuits with jelly. how many ML would the nurse record as the client's fluid intake? (round to nearest whole number, & use a leading zero if applicable)

660mL * 8oz+10oz+4oz+=22oz 1oz = 30 mL 30x22= 660mL

a nurse is caring for a client who's intake & output flow sheet for 0700 to 1500 (7am-3pm) indicates the following: voided x3: 350mL, 500mL, 150mL; wound drainage 2tsp; & emesis 2oz. what total output in milliliters should the nurse document for this 8hr period?

770 (mL)

Participative leader

A participative leader serves as a resource person and facilitator.

Transformational Leadership

A transformational leader gives group members responsibilities that will enhance their professional development.

A nurse in a mental health clinic is interviewing a client who has a history of substance use disorder. The client reports his experiences from a previous voluntary hospitalization. Which of the following reported experiences by the client constitutes assault? A. "I was threatened with a shot when I refused to take an oral medication that I knew would make me groggy." B. "I was held down against my will and administered a shot." C. "I was told I had to stay in the facility despite my request to leave." D. "I was exposed as a substance abuser to other clients in a group session."

Answer: A. Threatening to medicate clients against their wishes is assault. The tort of assault occurs when a person puts another in fear of nonconsensual contact. Incorrect Answers: B. Performing any procedure on a client without informed consent is battery, not assault. The tort of battery occurs when there is nonconsensual contact with one's person. C. Not allowing clients to leave a health care facility despite their wishes is false imprisonment, not assault. Mental health clients who admit themselves voluntarily to a psychiatric facility retain the right to sign themselves out of the facility. D. Sharing information with others not directly involved in the client's care is a violation of the client's confidentiality, not assault.

A nurse from a facility's float pool receives an assignment to float on a nursing unit. The float nurse tells the charge nurse that she has never worked on this unit before. How should the charge nurse respond? A. "I'll be sure to give you an easy assignment so you won't have any difficulty adjusting to our unit." B. "I will assign you to work with a registered nurse on the unit who is experienced and will act as a resource for you." C. "Don't worry about that. Come find me if you have any questions, and I will try to help." D. "I'll call the supervisor and ask if another float nurse is working who has experience with our unit."

Answer: B Providing the float nurse with a co-assigned resource person is appropriate. This resource is part of a float pool, not just a nurse floating from another unit, and it is likely that she will be assigned to this unit in the future. The charge nurse can facilitate her orientation to the unit by providing a resource person who is skilled in the care provided to clients on the unit. Incorrect Answers: A. While the charge nurse should not overwhelm the float nurse with a difficult assignment, providing the float nurse with an easy assignment will not address the need to be properly oriented to the unit. C. The charge nurse should provide the float nurse with a specific resource nurse who is skilled in the care provided to clients on the unit. D. It is appropriate to facilitate the float nurse's orientation to the unit by providing a resource instead of questioning her abilities by indicating that another nurse would be better.

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a MI. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? a. Troponin is an enzyme that indicates damage to the brain, heart, & skeletal muscle tissue b. Troponin is a lipid whose levels reflect the risk for coronary artery disease c. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart d. Troponin is a protein that helps transport O2 throughout the body

C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart--- Troponin is a myocardial muscle protein that releases into the bloodstream when there is injury to the myocardial muscle. Troponin levels are specific point-of-care testing for clients who are having a myocardial infarction.

A charge nurse is making daily assignments for a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Measuring vital signs B. Reinforcing an IV catheter dressing C. Conducting a preoperative admission assessment D. Showing a client how to use a walker

Correct Answer: A. Examples of tasks a nurse can delegate to an AP are measuring and documenting vital signs, performing postmortem care, and measuring and documenting intake and output. Incorrect Answers: B. Caring for invasive lines, performing triage, and creating a nursing care plan are not within an AP's range of function. C. Performing assessments, giving telephone advice, and interpreting data are not within an AP's range of function. D. Providing client education, evaluating the effectiveness of care, and inserting NG tubes are not within an AP's range of function.

A nurse manager notes that a full-time nurse has been absent from work 6 times over the last 6 weeks. Using a nonpunitive approach, which of the following actions should the nurse manager take? A. Verbally remind the employee about the facility's employment standards. B. Recommend that the employee review the facility's policy regarding absences. C. Inform the employee in writing about the facility's employment policy. D. Ask the employee for a written action plan after discussing the reasons for these absences.

Correct Answer: A. Verbal admonishment is the first step in the disciplinary process for this type of infraction. The employee might not know or remember the existing standard, and a verbal reminder may be sufficient to change the employee's behavior. Incorrect Answers: B. Recommending that the employee reviews the policy does not ensure that the employee will read and fully understand the employment standards. C. Written admonishment is the second step in the disciplinary process for this type of infraction. If the employee fails to make a positive behavioral change after being verbally reminded by the manager about the facility's employment standards, the nurse manager should inform the employee in writing. D. This is an example of performance-deficiency coaching, which the nurse manager should use to correct unacceptable behaviors over time.

A charge nurse is making assignments for an oncoming shift. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? A. A client who is to be discharged with a peripherally inserted central catheter (PICC) line B. A client who is disoriented and awaiting a transfer to a long-term care facility C. A client who is 16 hours postoperative following a total laryngectomy D. A client who is newly admitted for abdominal pain of unknown origin

Correct Answer: B. A client who is disoriented will need observation and reality orientation, which is within the LPN's scope of practice. The client's condition can also be categorized as stable since discharge to a long-term care facility is scheduled. Incorrect Answers: A. A client who has a PICC line will require discharge teaching related to PICC line home care. client teaching is not within the LPN's scope of practice. C. A client who has a new tracheostomy is not considered stable and will require frequent assessment, which is not within the LPN's scope of practice. D. A newly admitted client should be assessed by the nurse. This client will also be undergoing many diagnostic tests and will require frequent assessment, which is not within the LPN's scope of practice.

a nurse is preparing to administer iron dextran IV to a client. which of the following actions should the nurse plan to take? a. administer a small test dose before giving the full dose b. infuse the medication over 30 seconds c. monitors the client closely for hypertension after the infusion d. administer cyanocobalamin as an antidote if iron dextran toxicity occurs.

a, administer a small test dose before giving the full dose

A nurse is preparing to teach the health care team about the concept of critical pathways. Which of the following statements about the purpose of a critical pathway should the nurse plan to include? A. "A critical pathway is a plan of care specific to the nursing interventions necessary for client care." B. "A critical pathway is a tool that legally binds the health care facility to provide services as outlined." C. "A critical pathway is a multidisciplinary tool that guides client care and bases outcomes on an externally imposed timeline." D. "A critical pathway is a plan that may be the same for several similar diagnoses."

Correct Answer: C. A critical pathway outlines the actions that members of the health care team must complete in a timely manner to achieve desired client outcomes and an appropriate length of stay for the particular diagnosis. Incorrect Answers: A. Critical pathways address appropriate nursing care and actions that other disciplines are responsible for as well. They provide a holistic approach to the plan of care. B. Critical pathways are not legal documents. Critical pathways establish the standard of care in an institution, but variances from the pathway often occur for multiple reasons. Documentation of these variances is important, along with the revised plan to correct or address the variance. D. Critical pathways are developed for individual diagnoses. They are based on the typical interdisciplinary needs and length of stay for that particular diagnosis.

A nurse overhears two other nurses discussing a conflict they are having about who should complete certain client-care tasks. The nurses agree that they are tired of the conflict and will let the nurse manager decide who should complete the tasks. The nurse should identify this outcome as which of the following approaches to conflict management? A. Win-win B. Win-lose C. Win-yield D. Lose-lose

Correct Answer: C. A win-yield approach involves both parties no longer trying to resolve the conflict. Instead of taking the initiative to end the conflict, they agree to honor whatever the nurse manager decides. Incorrect Answers: A. A win-win strategy is a collaborative approach. There is no power struggle, and both parties work together for a positive outcome that meets a common goal. B. A win-lose strategy involves one party emerging victoriously and the other losing the struggle. If the losing party continues to pursue the situation, it becomes a competing strategy. D. A lose-lose strategy is also an AVOIDANCE approach. The two parties abandon the struggle and take no further action, but the conflict remains. In this outcome, no one wins.

While participating in a continuous QI program, a nurse is reviewing medical records to determine the time of first postop ambulation of clients who had abdominal surgery. In which type of quality audit is the nurse participating? A. Outcome B. Structure C. Strategic planning D. Process

Correct Answer: D. A process audit measures the interventions used to facilitate expected and desired outcomes for clients. Early ambulation is essential for the prevention of postop complications. Incorrect Answers: A. An outcome audit evaluates how the client's health status changed as a result of an intervention. B. A structure audit evaluates the relationship between quality care and appropriate structure and includes inputs such as the environment in which care is delivered. C. Strategic planning is done as a part of the planning process. It typically examines the purpose, mission, philosophy, and goals of an organization.

A charge nurse on a pediatric unit is delegating tasks to an assistive personnel (AP) who is pregnant and reports that she is unsure of her immune status. Which of the following clients should the charge nurse assign to the AP? A. A 9-year-old child who has fifth disease B. A 4-year-old child who has varicella (chicken pox) C. A 6-year-old child who has rubella D. A 2-year-old child who has impetigo contagiosa (impetigo)

Correct Answer: D. If the AP practices universal precautions, there is no risk of contracting impetigo. Impetigo is a superficial skin infection caused by either Staphylococcus or Streptococcus. Incorrect Answers: A. If the AP has never had fifth disease, the chance of contracting it is significant. Erythema infectiosum is a communicable disease and has been associated with early fetal loss. There is no immunization for fifth disease. B. If the AP has never had varicella or been immunized against it, the chance of contracting it is significant. Varicella is a communicable disease and a known teratogen. C. If the AP has never had rubella or been immunized against it, the chance of contracting it is significant. Rubella is a communicable disease and a known teratogen.

A nurse is caring for a client who has recently been prescribed lithium carbonate. Which of the following assessment findings is the priority for this client? A. Fine hand tremors B. Weight gain of 2.7 kg (6 lb) C. Report of nausea D. Poor motor coordination

Correct Answer: D. When using the urgent vs non-urgent approach to client care, the nurse should determine that the priority finding is poor motor coordination, which is an advanced manifestation of lithium carbonate toxicity. hold the client's medication and notify the provider. Incorrect Answers: B. Weight gain is an expected finding for a client who has recently been prescribed lithium carbonate and can be addressed using diet and exercise. C. Nausea is an expected finding for a client who has recently been prescribed lithium carbonate, and it may continue for a few weeks before subsiding.

A nurse is reviewing laboratory results for a client who is at 12 weeks gestation. Which of the following findings should the nurse report to the provider? A. Hgb 12 g/dL B. WBC 15,000/mm^3 C. Fasting blood glucose 80 mg/dL D. Serum creatinine 0.4 mg/dL

Correct Answer: D. Serum creatinine 0.4 mg/dL This value is below the expected reference range (adult women, 0.59 to 1.04 mg/dL) for a client who is pregnant. The nurse should report this value to the provider. The other values are within the expected reference range for a client who is pregnant.

A nurse is making a client's bed and finds a capsule of medication in the sheets. Which of the following actions by the nurse is consistent with safe nursing practice? (Select all that apply.) A. Administer the medication to the client. B. Notify the provider. C. Complete a variance report. D. Document the finding in the client's electronic medical record. E. Place the medication back in the medication drawer.

Correct Answers: B. C. B. The nurse should notify the provider of the finding as a part of the variance reporting process. C. The nurse should complete an incident or variance report regarding the occurrence. Incorrect Answers: D. The nurse should not document the finding in the client's electronic medical record. The nurse should identify that information in the client's medical record is subject to attorney review should the client decide, for any reason, to file suit against the facility or the healthcare staff. Instead, follow facility policy and report the incident to the nurse manager and risk management through the use of a variance report. In addition, avoid documenting in the medical record that a variance report was filed because this can also allow for the variance report to be subpoenaed should the client decide to file suit. E. The nurse should identify that medications that are no longer packaged are considered contaminated and should be discarded.

A nurse is providing discharge teaching about wound care to a client who has a leg wound. Which of the following pieces of information should the nurse include in the teaching? (Select all that apply.) A. Use cotton balls to clean the infected areas. B. Cleanse the wound with tap water. C. Dry the leg wound after cleaning. D. Microwave the cleaning solution before applying to the wound. E. Discard soiled bandages in a moisture-proof bag.

Correct Answers: B. E. Tap water or 0.9% sodium chloride should be used to cleanse the wound. Soiled bandages and gloves should be placed in double-bagged, moisture-proof bags and not in the regular trash. This prevents the spread of contamination to other family members within the household. Incorrect Answers: C. Drying the leg wound after cleaning should be avoided. The wound should be open to the air to allow the wound to retain moisture and promote healing. D. The nurse should warm the cleaning solution to the client's body temperature if possible; however, using a microwave to warm the solution can make it too hot.

A nurse is teaching dietary-modification strategies to a client who has been newly diagnosed with cirrhosis. Which of the following foods should the nurse recommend? a. grilled chicken b. potato soup c. fish sticks d. baked ham

a. grilled chicken

A nurse is teaching a group of newly licensed nurse managers about the principle of justice. Which of the following statements by a nurse manager indicates an understanding of this teaching? A. "I will refer an unhappy employee to the individual with whom a conflict arose." B. "I will allow staff members to schedule their birthday holidays on alternate days, as long as staffing levels are maintained." C. "I will encourage staff participation in choosing new telemetry monitors for the unit." D. "I will compose staff schedules so that each person works two holidays a year." Check Answer Question Feedback Close Explanation

D. Justice means treating everyone fairly. By scheduling each person to work two holidays per year, the nurse manager is requiring staff members to work an equal share of holidays. Incorrect Answers: A. This is an example of the appropriate use of conflict management. By referring unhappy staff members to the individuals with whom they have conflicts, the nurse manager is encouraging individual problem-solving behaviors. B. This demonstrates the principle of autonomy. By allowing staff members to participate in scheduling while maintaining appropriate levels of staffing, the nurse manager is encouraging independent, professional behavior. C. This is an example of change theory. By allowing staff members to participate in decision-making for the unit, the nurse manager is encouraging staff input in the change process.

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (select all that apply) a. tracheal deviation to the left b. temperature of 102 degrees c. absent breath sounds on the right side d. neck vein distention e. bradypnea

a, c, d A tension pneumothorax can occur following a thoracentesis. A trachea that is deviated to the unaffected side instead of being in the center of the neck is a manifestation of pneumothorax. Absent breath sounds on the affected side and neck vein distention are also manifestations of a pneumothorax. As the client's difficulty breathing increases, the blood flow return compresses, causing the neck veins to distend

1 latent conflict 2 perceived conflict 3 felt conflict 4 manifest conflict 5 conflict aftermath

The first stage of the conflict process is latent conflict, which involves awareness of potential situations that can create conflict. Stage 2 is perceived conflict, where those who are affected discuss the situation in an impersonal manner. Stage 3 is felt conflict, which occurs when those who are affected become personally involved. Stage 4 is manifest conflict and is signaled by those who are involved in taking action. In stage 5, or conflict aftermath, those who are involved recognize the positive and negative outcomes of how the situation was managed.

A nurse is preparing to transfuse 250 mL of packed red blood cells to a client over 4 hr. A blood administration set is available that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min?

X gtt/min = 10 gtt/1 mL x 1 hr/60 min x 250 mL/240 min X = 10.4 gtt/min

A nurse is teaching a client with chronic kidney disease about predialysis dietary recommendations. The nurse should recommend restricting the intake of which of the following nutrients? a. protein b. carbohydrates c. calcium d. monosaturated fats

a protein dietary restrictions for client who have chronic kidney disease vary based on the degree of kidney function; however, most clients need protein limitations. predialysis protein restriction can help preserve some kidney function

A nurse is preparing a client for an electroencephalogram (EEG). When the client asks the nurse what this test does, which of the following responses should the nurse provide? a. "An EEG measures the electric signals to your brain from hearing, sight, and touch." b. "An EEG measures the electrical activity in your muscles." c. "An EEG identifies the magnetic fields produced by electrical activity in your brain." d. "An EEG records the electrical activity of your brain cells."

a. "An EEG records the electrical activity of your brain cells."

A nurse is performing discharge about ostomy care while at home for a client who has a newly places ileostomy. Which of the following instructions should the nurse include in the teaching? a. "Empty your ostomy pouch when it becomes half full." b. "Place an aspirin in the ostomy pouch to eliminate odor." c. "Change the ostomy appliance every week." d. "Cleanse the site around the stoma with hydrogen peroxide and water."

a. "Empty your ostomy pouch when it becomes half full."

A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching? a. "I can snack on fresh fruit." b. "I can continue to eat lunch meat sandwiches." c. "I can have cottage cheese with my meals." d. "Canned soup is a good lunch soup."

a. "I can snack on fresh fruit."

A nurse is caring for a client whose surgeon informed him postoperatively that he has a metastasizing malignant neoplasm in the colon. Which of the following statements by the client should the nurse identify as an indication that the client understands this information? a. "I have cancer of the colon that has begun to spread." b. "I have growths in my bowel that the doctor can treat easily." c. "As long as my tumor doesn't get any bigger, I'll be okay." d. "There is not much point in having more treatments."

a. "I have cancer of the colon that has begun to spread."

A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching? a. "I need to lie still in bed during my brachytherapy treatment" b. "I will have an implant placed once a month during my brachytherapy treatment" c. "I must stay at least 3 feet away from others between brachytherapy treatments" d. "I should expect some blood in my urine after each brachytherapy treatment"

a. "I need to lie still in bed during my brachytherapy treatment" the nurse should confirm that the client understands the need to remain on bed rest with limited movement while the radioactive implant is in place to prevent dislodgement

A nurse is providing teaching to a client with cancer who is receiving external radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? a. "I need to protect the area from sunlight." b. "I'm going to apply a heating pad to the area after each treatment." c. "I'll massage the area once per day." d. "I'll wash off the markings after each therapy treatment."

a. "I need to protect the area from sunlight."

A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? a. "I should check my heart rate at the same time each day" b. "I don't have to take my antihypertensive medications now that I have a pacemaker" c. "I should keep a pressure dressing over the generator until the incision is healed" d. "I cannot stand in front of our new microwave oven when it is on"

a. "I should check my heart rate at the same time each day" the nurse should instruct the client to check the heart rate at the same time each day and to document the rate in a log for reporting to the provider

A nurse is teaching a client with heart disease about a low-cholesterol diet. Which of the following client statements indicates the teaching was effective? a. "I should remove the skin from poultry before eating it." b. "I will eat seafood once per week." c. "I should use margarine when preparing meals." d. "I can use whole milk in my oatmilk

a. "I should remove the skin from poultry before eating it."

A nurse is caring for a client who has burn injuries on his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? a. "I will be on a special shower table." b. "The water temperature will be very cool to ease my pain." c. "The nurse will use a firm-bristled brush to remove loose skin." d. "The nurse will use scissors to open small blisters."

a. "I will be on a special shower table."

A nurse is providing discharge instructions to a male client who is being treated for genital warts. Which of the following statements indicates that the client understands how to prevent the transmission of this sexually transmitted infection (STI)? a. "I will bring my sexual partner for treatment." b. "Now that I've had my first dose of medicine, I can resume sexual activity." c. "Once I have been treated, I don't have to use condoms anymore." d. "Once the treatment is complete and I am free of symptoms, I don't have to return to the clinic."

a. "I will bring my sexual partner for treatment."

A nurse is providing information to a client who is scheduled for an exercise electrocardiography test. Which of the following client statements indicates an understanding of the teaching? a. "I will not drink coffee 4 hr prior to my test." b. "I can eat a light meal 1 hr prior to the test." c. "I can have a cigarette up to 30 min prior to the test." d. "I will take my heart medication on the day of the test."

a. "I will not drink coffee 4 hr prior to my test."

A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements indicates that the client is adhering to the treatment plan? a. "I would never have believed I could get used to enjoying my food without salt." b. "My blood pressure device at home usually shows about 156 over 98 or so." c. "I make sure take my blood pressure medicine when I have headaches." d. "My blood pressure pills are very expensive. Could I take a cheaper medication?"

a. "I would never have believed I could get used to enjoying my food without salt." This statement implies that the client has stopped adding salt to food. Sodium restriction is a single aspect of the treatment plan, but it does indicate dietary adherence by the client

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? a. add gestures when speaking with the client b. ask-open ended questions c. limit visitors to a 2 at a time d. use different words if the client does not understand a statement

a. add gestures when speaking with the client

A nurse is teaching a client who has a cast on his left arm to treat a forearm fracture. Which of the following statements indicates that the client understands the teaching? a. "I'll call the doctor's office if my fingers get colder on the arm with the cast" b. " If I have any itching under the cast, I'll try to reach them and rest" c. "If my fingers swell, I should put a heating pad on them and rest" d. "If I have nay tingling under my cast, I'll know I need to move my fingers more"

a. "I'll call the doctor's office if my fingers get colder on the arm with the cast." the nurse should emphasize the importance of doing neurovascular checks and notifying the provider of any unexpected findings, such as temperature variances

A nurse is providing discharge teaching for a client who had a bone marrow transplant and has thrombocytopenia. Which of the following statements indicates that the client understands the precautions he must take at home? a. "I'll stick with soft foods for now." b. "My family will be bringing me fresh flowers today." c. "I'll use a new disposable razor each day." d. "I'll blow my nose more often to avoid nosebleeds."

a. "I'll stick with soft foods for now." thrombocytopenia is common after a bone marrow transplant. to prevent bleeding until the client's platelet count improves, the client should avoid hard foods that could cause mouth trauma

A nurse is providing teaching to a client who has type 2 diabetes mellitus about the pathophysiology of the disease. Which of the following statements by the client indicates an understanding of the teaching? a. "My cells are resistant to the effects of insulin." b. "My body breaks down sugars too efficiently." c. "My pancreas does not produce insulin." d. "My body produces antibodies against pancreatic beta cells."

a. "My cells are resistant to the effects of insulin.: A client who has type 2 diabetes mellitus will have resistance to insulin and a decrease in the secretion of insulin by the pancreatic beta cells

A nurse is providing discharge teaching to a client who has osteoarthritis. Which of the following instructions should the nurse include? a. "Rest frequently after periods of activity." b. "Perform your exercises only on days that you feel good." c. "Perform your exercises after applying cold packs to your joints." d. "Place a large pillow under your knees when lying down."

a. "Rest frequently after periods of activity." The joint pain in osteoarthritis is caused by deterioration of the synovial membranes and often worsens after activity. Rest usually helps relieve the pain, so performing activities at a comfortable pace with periods of rest is appropriate

A nurse is teaching a client who has human immunodeficiency virus about the early manifestations of acquired immune deficiency syndrome (AIDS). Which of the following statements should the nurse include in the teaching? a. "You can expect a persistent fever and swollen glands." b. "You can expect an elevated white blood cell count." c. "You can expect increased blood pressure and edema." d. "You can expect weight gain."

a. "You can expect a persistent fever and swollen glands."

A nurse is caring for a client who is undergoing conservative treatment for deep-vein thrombosis. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make? a. "Your body has a process called fibrinolysis that will eventually dissolve the clot." b. "Your body has a mechanism that will keep the clot stable in its present location." c. "The clot will break into tiny fragments and float harmlessly in your bloodstream." d. "Treatment with heparin will dissolve the clot and keep other clots from happening."

a. "Your body has a process called fibrinolysis that will eventually dissolve the clot." fibrinolysis is a process that breaks down a clot over time in the body. this process is a treatment option for clots that are not immediately life-threatning

A nurse is caring for a client who had a below the knee amputation for gangrene of the right foot. The client reports sensations of burning and crushing pain in the toes of the absent right foot. Which of the following statements should the nurse make? a. "this type of pain usually decreases over time as the limb becomes less sensitive." b. "try to look at the surgical wound as a reminder the limb is gone." c. "use a cold compress intermittently these pain sensations." d. "grief over the lost limb can sometimes cause denial that the limb is really gone."

a. "this type of pain usually decreases over time as the limb becomes less sensitive."

A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis surgery. Which of the following pieces of information should the nurse include? a. "you might need glasses after the surgery" b. "you may drive home after the procedure" c. "continue to wear your contact lenses until the day of the surgery" d. "expect complete healing and clear vision in about a week"

a. "you might need glasses after the surgery" LASIK is a type of refractive laser eye surgery that ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, overcorrection or undercorrection of refractive errors is possible, so some clients will need prescription eyeglasses despite having had LASIK surgery.

A nurse in the emergency department is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse assess first? a. a client who is difficult to arouse and is unable to respond to questions b. a client who has slurred speech and exhibits anger c. a client who reports nausea and vomiting d. a client who is uncooperative and has uncoordinated movements

a. a client who is difficult to arouse and is unable to respond to questions

a nurse is teaching about levodopa with a family member of a client who has Parkinson's disease. which of the following pieces of information should the nurse include? a. a full therapeutic response may take several months to happen b. the medication should be taken with high-protein foods c. a full therapeutic response might cause vivid dreams d. the medication is given at the onset of mild symptoms

a. a full therapeutic response may take several months to happen

A nurse is rewarming a client following coronary artery bypass graft surgery. For which of the following complications of the rewarming process should the nurse monitor the client? a. acidosis b. infection c. hypertension d. cardiac tamponade

a. acidosis metabolic acidosis associated with hypoxia can occur if a client is rewarmed too quickly. acidosis develops after the client starts to shiver and increased myocardial oxygen consumption. rewarming of the client after CABG should occur at a rate no faster than 1 degree Celsius per hour

A nurse is caring for an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mmHg, heart rate 102/min respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take? a. administer antihypertensive medication for blood pressure b. monitor to ensure the client's urinary output is 20mL/hr c. withhold pain medication to prepare the client for surgery d. take the client's vital signs every 2hr

a. administer antihypertensive medication for blood pressure the nurse should administer antihypertensive medication for elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall

a nurse is admitting a client who has measles. which of the following types of transmission precautions should the nurse initiate? a. airborne b. droplet c. contact d. protective environment

a. airborne

a nurse is caring for a client who has asthma & a prescription for zileuton. which of the following lab values should the nurse monitor while the client is taking this medication? a. alanine aminotransferase (ALT) b. WBC count c. Potassium d. Chloride

a. alanine aminotransferase (ATL)

A nurse in the emergency department is assessing a client who has pancreatitis. In which of the following laboratory results should the nurse expect to see an elevation? a. amylase b. potassium c. calcium d. hematocrit

a. amylase With pancreatitis, laboratory results typically show elevated amylase within 12-24 hrs. This level remains elevated for 2-3 days

A nurse in an acute care clinic is talking with a client who reports that the osteoarthritis pain in her knees is increasing each day. The client wants to discuss non-pharmacological approaches to help relieve her pain. Which of the following interventions should the nurse suggest? a. applying warm compress to sore joints b. decreasing the daily intake of dietary protein c. keeping joints in extension during rest periods d. limiting sleep 6-7 hr per night

a. applying warm compresses to sore joints

A nurse is assisting a provider with performing a paracentesis on a client. Which of the following actions should the nurse take? a. ask the client to empty his bladder before the procedure b. place the client leaning forward over the bedside table for the procedure c. inform the client he will be sedated during the procedure d. instruct the client to fast for 6hr prior to the procedure

a. ask the client to empty his bladder before the procedure

A nurse is developing a plan of care for a client who has gastroesophageal reflux disease. The nurse should plan to monitor the client for which of the following complications? a. aspiration b. infection c. anemia d. weight loss

a. aspiration aspiration is a common complication of GERD, which results when the esophageal sphincter malfunctions an allows gastric acid and undigested food to back up into the esophagus

A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications? a. aspiration of water b. infection of the stoma c. bleeding around the stoma d. skin breakdown around the stoma

a. aspiration of water

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the following interventions should the nurse include? a. avoid IM injections b. assess the client for ecchymosis once per shift c. do no allow the client to have visitors d. encourage daily flossing between teeth

a. avoid IM injections this client's platelet count of 48,000/mm^3 indicates thrombocytopenia; therefore, the nurse should avoid invasive procedures such as an IM injection which can increase the client's risk of bleeding

A nurse is caring for a client who has manifestations of acute tubular necrosis following transplantation. Which of the following interventions should the nurse anticipate for this client? (select all that apply) a. hemodialysis b. biopsy c. immunosuppression d. balloon agioplasty e. surgical repair

a. b. c.

A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse provide? (select all that apply) a. take allopurinol as prescribed b. exercise several times a week c. limit intake of foods high in purine d. decrease daily fluid intake e. avoid citrus juices

a. b. c.

A nurse is admitting a client who has cirrhosis. Which of the following prescriptions should the nurse anticipate? (select all that apply) a. obtain the client's PT and INR measurements b. administer lactulose 30 mL PO 4 times daily c. obtain daily weight and abdominal girth measurements d. administer a daily multivitamin e. place the client on a low-protein diet

a. b. c. d.

A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (select all that apply) a. jugular vein distention b. moist crackles c. postural hypotension d. increased heart rate e. fever

a. b. d

A nurse is caring for a client who is wearing a halo fixator. Which of the following interventions should the nurse implement? (select all that apply) a. monitor the client's vital every 4 hr b. monitor the client's pin site for loosening c. hold the halo device when turning the client d. check the client's skin to ensure the jacket is not applying pressure e. adjust the screws holding the client's halor device in place to ensure a proper fit

a. b. d.

A nurse is caring for a postmenopausal client who is concerned that she might have an elevated risk of breast cancer. After conducting a risk assessment, the nurse should identify which of the following factors as increasing the client's breast cancer risk? (select all that apply) a. increased breast density b. BMI of 32 c. having given birth to 5 children d. undergoing hormonal replacement therapy for 10 years e. having 1-2 alcoholic drinks per week

a. b. d.

A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? (select all that apply) a. "You'll have to lie for several hours after the procedure." b. "You'll receive medication to relax you before the procedure." c. "You'll feel a cool sensation after the injection of the dye." d. "You'll have to keep your leg straight after the procedure." e. "You'll have to keep your leg straight after the procedure." e. "You'll have to limit the amount of fluid you drink for the first 24 hr. "

a. b. d.

A nurse is providing preoperative teaching to a client who has lung cancer and will undergo a pneumonectomy. Which of the following statements should the nurse include? (select all that apply) a. "you will have a chest tube in place after surgery." b. "we'll frequently help you turn, cough, and breathe deeply after surgery." c. "you will have to remain in bed for about 2 days after the surgery." d. "we'll give you oxygen to support your breathing if you need it." e. "you should expect pain for the first few days after surgery."

a. b. d.

A nurse is updating the plan of care for a client who is to receive total parenteral nutrition. Which of the following actions should the nurse include in the plan? (select all that apply) a. weigh the client daily b. obtain a serum blood glucose every 4 hr c. apply a new dressing to the client's IV site every 5 days d. change the IV tubing every 24 hr e. infuse the TPN through a peripheral IV site

a. b. d.

A nurse is planning postoperative education for a client who will undergo a radial neck dissection for cancer of the larynx. The nurse should include which of the following topics? (select all that apply) a. NPO status b. alternative methods of communication c. endotracheal intubation d. changes in body image c. swallowing exercises

a. b. d. e.

A nurse is talking with an older adult client who has elevated risk for osteoporosis about strategies for preventing bone loss. Which of the following instructions should the nurse provide? a. begin a program of brisk walking b. take 800 mg of calcium per day c. drink plenty of sparkling water d. drink 8 oz of red wine each day

a. begin a program of brisk walking weight-bearing exercises help maintain bone mass and prevent osteoporosis. walking is generally a safe activity for older clients

A nurse in the emergency department is caring for a client who has a fruity breath odor, a dry mouth, and extreme thirst. Which of the following assessments should the nurse make? a. blood glucose level b. pupillary reaction to light c. deep tendon reflexes d. liver function tests

a. blood glucose level

A nurse is assessing a client who is 1 week postoperative following a living donor kidney transplant. Which of the following findings indicates the client is experiencing acute kidney rejection? a. blood pressure 160/90 mmHg b. creatinine 0.8 mg/dL c. sodium 137 mg/dL d. urinary output 100 mL/hr

a. blood pressure 160/90 due to the kidneys' role in fluid and blood pressure regulation, a client who is experiencing rejection can have hypertension

A nurse is assessing a client who has cholecystitis. Which of the following findings should the nurse expect? a. blumberg's sign b. ascites c. gastrointestinal bleeding d. kehr's sign

a. blumberg's sign the nurse should expect to find rebound tenderness in a client who has cholecystitis. this response can be indication of peritoneal inflammation

A charge nurse receives notification of the admission of the client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (select all that apply) a. assign the client to a private room with negative-pressure airflow b. add contact precautions to the client's plan of care c. wear and N95 respirator when entering the client's room d. ensure the client's environment provides 4 exchanges of fresh air per minute e. institute protective environment precautions as soon as the client arrives on the unit

a. c. the client history an present status suggest tuberculosis, a communicable infection that mandates a private room with negative-pressure airflow. airborne precautions will be requires, including wearing an N95 respirator when entering the client's room

A nurse is caring for a client with a hip fracture who has Buck's extension traction in place. Which of the following pieces of information should the nurse give the client about this type of traction? (select all that apply) a. "You'll have considerably less pain with the traction in place." b. "You'll have the traction in place for a week or so." c. "The traction will help decrease muscle spasms." d. "The weights act as a pulling force to keep your leg and hip still." e. "We have to make sure the weights are just barely touching the floor."

a. c. d.

A nurse is assessing a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find. (select all that apply) a. hardening along the blood vessel b. absence of a peripheral pulse c. tenderness in the calf d. cool skin on the leg e. increased leg circumference

a. c. e

A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? (select all that apply) a. assess and document the client's vital signs b. restart the IV with a 22-gauge needle c. verify with another nurse the blood type and Rh of the packed RBCs d. hang a bag of lactated Ringer's IV solution e. change IV tubing to a set that has a filter

a. c. e.

A nurse is caring for a client who recently had chemotherapy and now has myelosuppression. Which of the following interventions should the nurse initiate? (select all that apply) a. prohibit visitors from bringing fresh flowers and plants into the client's room b. encourage frequent visits from family and friends c. ensure thorough cleaning of the clients room and bathroom daily d. replace wound dressings every other day e. use dedicated equipment such as stethoscopes

a. c. e.

A nurse on an oncology unit is providing discharge teaching to an adolescent female client who received a bone marrow transplant for leukemia. Which of the following pieces of information should the nurse include in the teaching? a. "take your temperature twice each day" b. "you may return to school if you feel strong enough" c. "it is important to wear shoes always". d. "clean your toothbrush weekly with isopropyl alcohol" e. "avoid using tampons"

a. c. e.

A nurse is planning for a client who is receiving chemotherapy and has a protein deficiency. Which of the following interventions should the nurse include in the plan of care? (select all that apply) a. mix powdered skim milk into liquid milk b. add a raw egg to fruit smoothies c. add a slice of cheese to hot vegetables d. add honey to hot tea e. mix yogurt into fresh fruit

a. c. e. dairy products are good sources of protein. mixing powdered skim milk into liquid milk can provide the client with additional protein. adding cheese to a vegetable can increase the client's protein intake. adding yogurt to fresh fruit will increase the client's protein intake

A nurse is caring for a client who is postoperative following a parathyroidectomy to treat hyperparathyroidism. Which of the following laboratory values should the nurse expect to decrease as a therapeutic effect of the procedure? a. calcium b. sodium c. potassium d. phosphorous

a. calcium Parathyroid hormone regulates calcium, phosphorus, and magnesium balance within the client's blood and bones by maintaining mineral levels. Hyperparathyroidism is associated with hypercalcemia; therefore, a decreased calcium level indicates an improvement in the client's condition

A nurse is providing a dietary teaching to a client who has late-stage chronic kidney disease. Which of the following nutrients should the nurse instruct the client to increase in her diet? a. calcium b. phosphorous c. potassium d. sodium

a. calcium a client who has CKD can develop hypocalcemia due to the reduced production of active vitamin D, which is needed for calcium absorption. the client should supplement dietary calcium

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? a. children b. older adults c. women who are pregnant d. middle-aged men

a. children

a nurse is caring for a client during her first prenatal visit & notes that she is lactose intolerant. which of the following foods should the nurse include on a list of calcium sources for this client a. collard greens b. cottage cheese c. orange juice d. broccoli

a. collard greens

a nurse is caring for a group of clients on a medical surgical unit. which of the following disorders should the nurse identify as increasing the clients metabolic needs? (select all that apply) a. copd b. hyperthyroidism c. cancer d. Parkinson's disease major burns

a. copd c. cancer d. Parkinson's disease e. major burns

A nurse is planning care for a client who has acute systemic lupus erythematosus (SLE) and is scheduled to begin treatment for systemic manifestations. Which of the following types of medications should the nurse plan to administer? a. corticosteriods b. antimalarials c. antidepressants d. opiods

a. corticosteroids corticosteroids such as prednisone are the treatment of choice for systemic manifestations of SLE because of their rapid anti-inflammatory action

A nurse is caring for a client who is 3 days postoperative following abdominal surgery. The client states, "Something just popped when I coughed." Which of the following actions should the nurse take first? a. cover the client's wound with a sterile, moist dressing b. flex the client's knees c. reassure the client d. instruct the client to avoid coughing

a. cover the client's wound with a sterile, moist dressing

A nurse is providing discharge instructions for a client who is postoperative following inner maxillary fixation with wiring. Which of the following pieces of information should the nurse include? a. cut the wiring if emesis occurs b. consume 3 meals daily as part of a low-protein diet c. swab the mouth with hydrogen peroxide if wiring produces oral irritation d. resume a soft diet in 3-5 days

a. cut the wiring if emesis occurs inner maxillary fixation involves wiring of the teeth to support the fractured jaw by holding the jawbones together. the wires are left in place until the fracture is healed. to preserve the client's airway, the nurse should instruct the client to have wire cutters available to cut the wiring immediately if emesis occurs.

A nurse is caring for a client who had a thyroidectomy to treat hyperthyroidism caused by an adenoma. Which of the following findings should the nurse report to the provider? (select all that apply) a. tachycardia and hypertension b. respiratory rate 16/min d. negative chvostek's c. laryngeal stridor and hoarseness e. positive trousseau's sign

a. d. e

A nurse is determining a client's risk of developing osteoporosis. The nurse should identify which of the following as risk factors for bone loss? a. small body frame b. hypertension c. african-american ethnicity d. low vitamin D intake e. smoking

a. d. e.

a nurse is caring for a client who has acute renal failure. which of the following assessments provides the most accurate measure of the clients fluid status? a. daily weight b. blood pressure c. specific gravity d. intake & output

a. daily weight

A nurse is reviewing the laboratory findings of a client who has protein calorie malnutrition. Which of the following findings should the nurse expect? a. decreased albumin b. elevated hemoglobin c. elevated lymphocytes d. decreased cortisol

a. decreased albumin a decrease in the albumin level can be an indication of a long-term protein depletion. other potential conditions that result in decreased albumin levels include burns, wound drainage, and impaired hepatic function

A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? a. discuss ways the client can reduce the number of cigarettes smoked per day b. suggest the client switch from smoking cigarettes to smoking a pipe c. inform the client that treatment will be ineffective if smoking continues d. discourage the use of nicotine gum

a. discuss ways the client can reduce the number of cigarettes smoked per day the nurse should discuss ways the client can reduce the number of cigarettes smoked per day to assist the client in creating a realistic goal to decrease smoking gradually

a nurse is preparing to administer amlodipine to a client who has hypertension. the nurse should plan to monitor the client for which of the following adverse effects of the medication? (select all that apply) a. dizziness b. pale appearance c. palpitations d. abdominal pain e. peripheral edema

a. dizziness c. palpitations e. peripheral edema

A nurse is assessing a client who has a head injury with a possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve? a. dizziness and hearing loss b. weakness of a side of the tongue c. facial droop and asymmetrical smile d. loss of the same visual field in both eyes

a. dizziness and hearing loss these symptoms reflect alterations in the vestibulocochlear area, which CN VII inneravates

A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions should the nurse include? a. limit fluid intake b. limit caloric intake c. eat a diet high in phosphorus d. eat a diet high in protein

a. limit fluid intake a client who had CKD should limit fluid intake to prevent hypervolemia

A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal sage of inhalation anthrax? a. dry cough b. rhinitis c. sore throat d. swollen lymph nodes

a. dry cough a dry cough is a clinical manifestation of the prodromal stage of inhalation anthrax. during this stage, it is difficult to distinguish the condition from influenza or pneumonia because there is no sore throat or rhinitis

A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement? a. dysphagia b. positive babinski sign c. decreased deep-tendon reflexes d. ataxia

a. dysphagia

A nurse is providing teaching about degenerative complications to the partner of a client who has a new diagnosis of Parkinson's disease. Which of the following manifestations is the priority? a. dysphagia b. emotional lability c. impaired speech d. self-care dependency

a. dysphagia

A nurse is monitoring a client who is undergoing extracorporeal shockwave lithotripsy. The nurse should identify that which of the following findings is the priority? a. dysrhythmias b. pink-tinged urine c. bruising on the flank area d. stone fragments in the urine

a. dysrhythmias

A nurse is teaching a client who has a colostomy about ways to reduce flatus and odor. Which of the following strategies should the nurse include? a. eat crackers and yogurt regularly b. chew minty gum throughout the day c. drink orange juice every day d. put an aspirin in the pouch

a. eat crackers and yogurt regularly

A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods? a. eggs b. squash c. kale d. tofu

a. eggs

A nurse is caring for a client who has a femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? a. elevate the affected leg b. place the client on bed rest c. massage the affected leg d. administer aspirin for discomfort

a. elevate the affected leg

A nurse is examining the ECG on a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? a. elevated ST segments b. absent P waves c. depressed ST segments d. varying PP intervals

a. elevated ST segments

A nurse is planning care for a client who has type 2 diabetes mellitus. Which of the following interventions should the nurse include in the plan? a. encourage the client to control weight b. inspect the client's feet once each week c. restrict the client's activity d. apply moisturizer between the client's toes

a. encourage the client to control weight the nurse should encourage weight control to stabilize the client's blood glucose and improve glycosylated hemoglobin levels. Obesity is risk factor factor for type 2 diabetes, and moderate calorie restriction can improve control of diabetes

A nurse is caring for a client who has an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take? a. ensure bowel rest b. offer sparkling water frequently c. administer a stool softener d. offer plain warm tea frequently

a. ensure bowel rest clients who have an exacerbation of Crohn's disease usually require NPO status to ensure bowel rest and promote healing and recovery

A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The client's hemoglobin level is 8g/dL. The nurse should expect a prescription for which of the following medications? a. erythropoietin b. erythromycin c. filgrastim d. calcitriol

a. erythropoietin erythropoietin stimulates the production of RBCs and is used to treat anemia associated with chronic renal failure

A nurse is teaching a female client with a new diagnosis of systemic lupus erythematosus about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching if she identifies which of the following as an exacerbation factor? a. exercise b. pregnancy c. infection d. sunlight

a. exercise SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks healthy body tissue. this attack results in generalized inflammation and creates manifestations associated with the specific involved tissues. most clients who have SLE can follow an exercise program to increase their cellular aerobic capacity and improve immune function, and the client should follow a program with her provider's assistance. this client needs additional teaching about the importance of exercise to keep her muscles and joints active

A nurse is caring for a client who has a hearing impairment. Which of the following actions should the nurse take when communicating with the client? a. face the client when speaking b. speak in a loud voice c. use a normal rate when speaking d. avoid hand motions

a. face the client when speaking

A nurse is caring for a client who has osteoporosis and a new prescription for calcium supplements. Which of the following foods should the nurse recommend to promote calcium absorption? a. fortified milk b. ripe bananas c. steamed broccoli d. green leafy vegetables

a. fortified milk

A nurse is caring for a client with a history of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? a. gamma-glutamyl transferase (GGT) b. alkaline phosphatase (ALP) c. serum bilirubin d. alanine aminotransferase (ALT)

a. gamma-glutamyl transferase (GGT)

A nurse is planning an educational program for a group of young adults about reducing the risk of cervical cancer. Which of the following interventions should the nurse include? a. get the HPV immunization b. avoid the use of tampons on a routine basis c. avoid drinking alcohol d. get a papanicolaou test every year starting at age 30

a. get the HPV immunization

A nurse is checking laboratory values to determine if a client with diabetes mellitus is adhering to the treatment plan. Which of the following tests should the nurse use to make this determination? a. glycosylated hemoglobin levels b. urine sugar and acetone levels c. glucose tolerance test d. fasting serum glucose

a. glycosylated hemoglobin levels

A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use? a. have the client open his mouth and say, "ahh" b. ask the client to identify the scent of coffee c. use a tongue blade to provoke a gag reflex d. have the client smile and raise eyebrows

a. have the client open his mouth and say, "ahh" the vagus or X nerve has both sensory and motor function. to test the motor function, the nurse should have the client open his mouth and say, "ahh". the palate and the uvula should move upward in response. the nurse should also assess the client's voice quality for hoarseness

A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was places on airborne precautions, and is scheduled for chest x-ray. The nurse should instruct the newly licensed nurse to take which of the following actions? a. have the client wear a surgical mask b. wear a gown for protection from the client c. ask the radiology staff to perform a portable chest x-ray in the client's room d. place a N-95 respirator on the client

a. have the client wear a surgical mask the mask will protect anyone who comes into contact with the client, including the nurse

a nurse is caring for a client who has a new prescription for levothyroxine to treat hypothyroidism. which of the following findings should the nurse identify as an indication that the client requires intervention? a. heart rate 106/min b. dry skin c. oral temp 36.8C (98.2F) d. leathery

a. heart rate 106/min

a nurse is preparing to administer dantroline to a client who has muscle spasticity. which of the following findings from the client's medical history should the nurse identify as a contraindication to the administration of this medication? a. history of cirrhosis b. history of multiple sclerosis c. history of cerebral palsy d. history of malignant hyperthermia

a. history of cirrhosis

a nurse is teaching a group of parents of toddlers about measures to reduce the risk of choking. which of the following foods increase the risk of choking in toddlers? (select all that apply) a. hot dogs b. grapes c. bagels d. marshmallows e. graham crackers

a. hot dogs b. grapes c. bagels d. marshmallows

A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? a. hyperkalemia b. hyponatremia c. hypercalcemia d. hypomagnesemia

a. hyperkalemia

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? a. hypokalemia b. hypophosphatemia c. hypercalcemia d. hypermagnesemia

a. hypokalemia

A nurse is assessing a client who has Addison's disease. Which of the following findings should the nurse expect? a. hypotension b. weight gain c. sugar craving d. pale skin tone

a. hypotension the nurse should expect hypotension in a client who has adrenal insufficiency. the nurse should monitor the client's blood pressure closely.

a nurse is teaching about adverse effects of ergotamine with a client who has migraine headaches. which of the following client statements should indicate an understanding of the teaching? a. if I overuse this medication, I might become addicted to it. b. this medication is okay to use during pregnancy c. tingling in my fingers & toes is an adverse effect that goes away with continued use d. I will experience restlessness as an adverse effect when I begin taking this medication

a. if I overuse this medication, I might become addicted to it

A nurse in the emergency department is caring for a client who has a snakebite on her arm. Which of the following interventions should the nurse implement? a. immobilize the limb at the level of the heart b. apply a tourniquet to the affected limb c. use a sterile scapula to incise the wound d. apply ice to the skin over the snakebite wound

a. immobilize the limb at the level of the heart the emergency department management of a client who has a snakebite focuses on limiting the spread of venom. any constrictive clothing or jewelry should be removed before swelling worsens, and the affected limb should be immobilized at the level of the heart.

A nurse is teaching a client about the manifestations of an allergic reaction. The release of histamine causes which of the following reactons? a. increased mucus secretion b. bronchial dilation c. bradycardia d. vertigo

a. increased mucus secretion the nurse should instruct the client that increased mucus secretion is a manifestation of histamine release. histamine is the neurotransmitter the body produces during an allergic reaction

A nurse is assessing a client who has an isotonic dehydration. Which of the following findings should the nurse expect? a. increased hematocrit level b. bradycardia c. distended neck veins d. decreased urine specific gravity

a. increases hematocrit the nurse should expect the client to have an increased hematocrit level due to hemoconcentration caused by reduced plasma fluid volume

A nurse is admitting a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurse's priority? a. initiate airborne precautions b. administer antimicrobial therapy c. tell the client that the infection will be communicable for 2-3 weeks from the start of medication therapy d. teach the client about the manifestations of tuberculosis

a. initiate airborne precautions

a nurse is providing teaching to a client who has ulcerative colitis & a new prescription for sulfasalazine. the nurse should instruct the client to monitor for which of the following advise effects of this medication? a. jaundice b. constipation c. oral candidiasis d. sedation

a. jaundice

A nurse is teaching a client who has iron deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? a. lentils b. avocados c. cabbage d. broccoli

a. lentils the nurse should encourage the client to increase her consumption of iron-rich foods, including meat, fish, poultry, and dried beans and peas. A 1-cup serving of lentils contains 3.6 mg of iron

A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? a. lentils b. avocados c. cabbage d. broccoli

a. lentils the nurse should encourage the client to increase her consumption of iron-rich foods, including meat, fish, poultry, and dried beans and peas. a 1-cup serving of lentils contains 3.6 mg of iron

a nurse is planning care for a client who is receiving chemotherapy & has a protein deficiency. which of the following interventions should the nurse include n the plan of care? (select all that apply) a. mix powdered skim milk into liquid milk b. add a raw egg to fruit smoothies c. add a slice of cheese to hot veggies d. add honey to hot tea e. mix yogurt into fresh fruit

a. mix powdered skim milk into liquid milk c. add a slice of cheese to hot veggies e. mix yogurt into fresh fruit

a nurse is caring for a client who s experiencing an acute gout attack. the nurse should anticipate a prescription from the provider for which of the following medications? a. naproxen b. pegloticasr c. probenecid d. allopurinol

a. naproxen

A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments of the ECG indicate which of the following alterations? a. necrosis b. hypokalemia c. hypomagnesemia d. insufficiency

a. necrosis ST-segment elevation during an acute myocardial infarction indicates necrosis. this ECG change reflects a clot at the site of injury. therefore, the client requires immediate revascularization of the artery

A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? a. offer the client a bedpan every 2 hr b. limit the client's daily fluid intake until he is no longer incontinent c. request a prescription for an indwelling urinary catheter from the client's provider d. ambulate the client to the bathroom every 30 min

a. offer the client a bedpan every 2 hr

A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the client's plan of care? a. offering the client a diet high in fluid and fiber b. encouraging active range of motion of the affected leg c. removing the weights prior to repositioning the client d. inspecting pin sites every 24 hr for drainage

a. offering the client a diet high in fluid and fiber a client who is immobile is at risk of constipation. the nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function

A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client? a. omega-3 fatty acids b. antioxidants c. vitamins A, D, and C d. beta-carotene

a. omega-3 fatty acids

A nurse is recommending dietary modifications for a client who has GERD. The nurse should suggest which of the following foods from the client's diet? a. oranges and tomatoes b. carrots and bananas c. potatoes and squash d. whole wheat and beans

a. oranges and tomatoes

A nurse is preapring to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? a. hyperventilate the client with 100% oxygen prior to obtaining the specimen b. apply ice to the site after obtaining the specimen c. perform an Allen's test prior to obtaining the specimen d. release the pressure applied to the puncture site 1 min after the needle is withdrawn

a. perform an Allen's test prior to obtaining the specimen

A nurse is caring for an older adult client who had an acute myocardial infarction. When assessing this client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age-related factors? a. peripheral vascular resistance increases b. the sensitivity of blood pressure-adjusting baroreceptors increases c. blood is hypercoagulable and clots more quickly d. cardiac medications are less effective

a. peripheral vascular resistance increases older adult clients are more prone to complications from poor tissue perfusion following an acute MI because peripheral vascular resistance increases with aging. this results from calcification and loss of elasticity of the blood vessels

a nurse is caring for a client who received spinal anesthesia 30 minutes ago. the client reports feeling dizzy, & the nurse notes that the client's blood pressure is 88/54 mmGh. which of the following actions should the nurse take? a. place the client in the head down position b. assess the placement of the catheter c. prepare to administer an IV reversal agent d. assist the client in passive range of motion movements

a. place the client in the head down position

a nurse is caring for an older adult client who has dementia. the client becomes agitated & confused at night & wanders into the hallway. which of the following actions should the nurse take? a. place the client's mattress on the floor b. restrain the client during nighttime hours c. provide continuous orientation to the client d. turn out the lights in the client's room at night

a. place the client's mattress on the floor * to ensure the client's safety & prevent falls related to nighttime confusion, the nurse should place the clients mattress on the floor

A nurse is monitoring a client who has a syndrome of inappropriate antidiuretic hormone secretion. Which of the following findings should the nurse expect? a. polyuria b. dehydratioin c. hyponatremia d. hyperthermia

a. polyruria

A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take? a. position the client supine with his legs elevated when in bed b. encourage the client to ambulate for 15 min every hour while awake for the first 24 hr c. tell the client to sit with his legs dependent after ambulating d. instruct the client to wear knee-length socks for 2 weeks after surgery

a. position the client supine with his legs elevated when in bed the nurse should elevate the client's legs above his heart to promote venous return by gravity. during discharge teaching the nurse should reinforce the importance of periodic positioning of the legs above the heart

A nurse is preparing to provide self-care teaching to a client who is 4 days postoperative following the creation of a colostomy and refuses to look at the stoma. Which of the following actions should the nurse take? a. postpone any teaching with the client at this time b. reinforce the preoperative information with the client c. encourage the client to empty the colostomy bag first d. ask the client to begin assuming responsibility for self-care of the colostomy

a. postpone any teaching with the client at this time the nurse should postpone any teaching at this time and should encourage the client to look and touch the stoma before continuing to teach about self-care.

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? a. potassium 2.8 b. digoxin level 0.7 c. hemoglobin 9.8 d. calcium 8

a. potassium 2.8

A nurse is checking the laboratory values of a client who has chronic kidney disease. The nurse should expect elevations in which of the following values? a. potassium and magnesium b. calcium and bicarbonate c. hemoglobin and hematocrit d. arterial pH and PaCO2

a. potassium and magnesium clients who have chronic kidney disease have hyperkalemia, hyperphosphatemia, and hypermagnesemia as well as elevations in serum creatinine and blood urea nitrogen

a nurse is providing teaching to a female client who has a new prescription for pravastatin to treat hyperlipidemia. which of the following pieces of information should the nurse include in the teaching? a. pravastatin can be taken with grapefruit juice b. pravastatin can be continued during pregnancy c. pravastatin should be taken with the morning meal d. laboratory testing to monitor the client's WBC count is required

a. pravastatin can be taken with grapefruit juice.

A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes? a. a. prevents excessive pressure on suture lines b. allows gastric lavage after surgery c. allows early postoperative feeding d. facilitates obtaining gastric specimens for testing

a. prevents excessive pressure on suture lines the NG tube remains in place after surgery to prevent excessive pressure on suture lines postoperatively. it drains the air and fluid that can cause pressure from inside the gastrointestinal tract. in doing so, it also prevents vomiting and GI distention

A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes? a. prevents excessive pressure on suture lines b. allows gastric lavage after surgery c. allows early postoperative feeding d. facilitates obtaining gastric specimens for testing

a. prevents excessive pressure on suture lines the NG tube remains in place after surgery to prevent excessive pressure on suture lines postoperatively. it drains the air and fluid that can cause pressure from inside the gastrointestinal tract. in doing so, it also prevents vomiting and GI distention

A nurse is teaching a client who has Raynaud's disease. Which of the following pieces of information should the nurse include in the teaching? a. protect against the cold by wearing layers of clothing b. begin an exercise program of 2-mile walks once per week c. increase vitamin A in the diet d. elevate the hands about heart level when resting

a. protect against the cold by wearing layers of clothing

a nurse is teaching a client with chronic kidney disease about predialysis dietary recommendations. the nurse recommending restricting the intake of which of the following nutrients? a. protein b. carbs c. calcium d. monounsaturated fats

a. protein

A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasms. Which of the following laboratory results should the nurse review? a. prothrombin time b. WBC count c. platelet count d. hematocrit

a. prothrombin time the nurse should review the clients prothrombin time after the administration of FFP, which is plasma-rich in clotting factors. FFP is administered to treat acute clotting disorders. the desired effect is a decrease in the prothrombin time

a nurse is reviewing the medical record of a client. the medication administration records shows the client is taking clopidogrel. which of the following events should the nurse expect in the client's medical history? a. recent myocardial infarction b. history of hemorrhagic stroke c. current outbreak of psoriasis d. history of hypertension

a. recent myocardial infarction

A nurse is providing discharge teaching to a client who has had a transient ischemic attach. Which of the following instructions should the nurse include? a. reduce dietary sodium b. decrease dietary potassium c. restrict intake of insoluble fiber d. limit alcohol intake to equal to or less than 3 serving per day

a. reduce dietary sodium a temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurological function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should limit sodium intake to help control hypertension and prevent future TIAs

A nurse is providing discharge teaching to a client who has had transient ischemic attack. Which of the following instructions should the nurse include? a. reduce dietary sodium b. decrease dietary potassium c. restrict intake of insoluble fiber d. limit alcohol intake to < or equal to 3 servings per day

a. reduce dietary sodium a temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurological function. the most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should limit sodium intake to help control hypertension and prevent future TIAs

a nurse is preparing to administer IV nitroprusside for a client who had a myocardial infarction. which of the following actions should the nurse make? a. regulate the infusion pump rate using the client's weight in the calculation b. change the iv solution bag every 48 hours after the time of preparation c. ensure the freshly prepared iv solution has a slight greenish tint d. cover the medication with an amber plastic bag to protect it from light

a. regulate the infusion pump rate using the client's weight in the calculation

A nurse is caring for a client who has a diagnosis of renal calculi and reports flank pain. Which of the following is the priority nursing action? a. relieve the client's pain b. encourage the client to increase fluid intake c. monitor the client's intake and output d. strain the client's urine

a. relieve the client's pain

During a neurological assessment, a nurse asks the client to name all of his children, their ages, and their birth dates. Which of the following types of memory is the nurse testing? a. remote b. sensory c. immediate d. recall

a. remote

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? a. right shoulder pain b. urine output 20 mL/hr c. temperature of 101.1 d. oxygen saturation 92%

a. right shoulder pain The client can experience pain in the right shoulder due to gas injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm can cause reffered pain in the shoulder area.

A nurse is providing teaching to a client who has type 1 diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include in the teaching? a. shakiness b. urinary frequency c. dry mucous membranes d. excess thirst

a. shakiness a client who has hypoglycemia can experiences early manifestations of shakiness, as well as fatigue, a headache, difficulty thinking, sweating, and nausea

a nurse is caring for school-aged child who has cystic fibrosis (CF) & has been using a corticosteroid inhaler for long-term treatment. which of the following findings should the nurse identify as an adverse effect of long-term use of this medication a. small stature for age b. decreased weight c. poor dentition d. atrophied muscles

a. small stature for age

A nurse in a medication-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestations of pulmonary embolism? a. stabbing chest pain b. calf tenderness c. elevated temperature d. bradycardia

a. stabbing chest pain a manifestation of pulmonary embolism is sudden chest pain that is sharp and stabbing. other manifestations include dyspnea, coughing, hemoptysis, tachypnea, tachycardia, diaphoresis, and a feeling of impending doom

A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect? a. swelling behind the affected ear b. facial drooping on the affected side c. nystagmus on the affected side d. pearly gray color of the affected eardrum

a. swelling behind the affected ear

a nurse is caring for a client who has a prescription for subnormal etonogestrel. the nurse should alert the provider about which of the following findings in the clients medical history? a. takes St. Johns wort b. breastfeeds a 6 month old infant c. has a parent with hypertension d. has a positive human papilloma virus (HPV) test result

a. takes st. johns wort

A nurse is caring for a client who has a demand pacemaker inserted with a set rate of 72/min. Which of the following findings should the nurse expect? a. telemetry monitoring showing QRS complexes occuring at a rate of 74/min with no pacing spikes b. premature ventricular complexes at 12/min c. telemetry monitoring showing pacing spikes with no QRS complexes d. hiccups

a. telemetry monitoring showing QRS complexes occuring at a rate of 74/min with no pacing spikes The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min because the client's intrinsic rate overrides the set rate of pacemaker

a nurse is teaching a client with type 2 diabetes mellitus about self administration of a new prescription for acarbose. which of the following pieces of information should the nurse include? a. tell the client to take the medication with food b. show the client how to perform an intramuscular injection c. advise the client to avoid taking this medication with insulin d. warn the client against exercising while taking this medication

a. tell the client to take the medication with food

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? a. the client rigidly extends his arms b. the client internally flexes his wrists c. the client curls into a fetal position d. the client internally rotates his legs

a. the client rigidly extends his arms

A nurse is teaching a newly licensed nurse about caring for a client who is scheduled for an esophagogastric balloon tamponade tube to treat bleeding esophageal varices. Which of the following pieces of information should the nurse include in the teaching? a. the client will be placed on mechanical ventilation prior to this procedure b. the tube will be inserted into the client's trachea c. the client will receive a bowel preparation with cathartics prior to this procedure d. the tube allows the application of a ligation band to the bleeding varices

a. the client will be placed on mechanical ventilation prior to this procedure The client will require intubation and mechanical ventilation prior to this procedure to protect the airway

A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority? a. the client's ability to clear oral secretions b. the client's ability to communicate verbally c. the client's ability to move all extremities d. the client's ability to remain continent of urine

a. the client's ability to clear oral secretions the first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to check the client's ability to clear secretions in order to protect the airway and reduce the risk of aspiration.

A nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation tibia. Which of the following findings should the nurse report to the provider? a. toes that are cold to the touch b. serous drainage from the pin sites c. blanching of the toenail beds with pressure d. pink tissue around the fixator insertion sites

a. toes that are cold to the touch the nurse should monitor and report manifestations of compartment syndrome following internal fixation. therefore, the nurse should contact the provider immediately if the client's toes are cold to the touch

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? a. total lung capacity b. vital lung capacity c. functional residual capacity d. residual volume

a. total lung capacity

A nurse is reviewing the menu selections of a client who has heart failure and anticipates discharge to home the following day. Which of the following lunch choices should the nurse identify as an indication that the client understands his dietary instructions? a. turkey on whole-wheat bread b. hamburger and french fries c. frankfurter on a white roll d. macaroni and cheese

a. turkey on whole-wheat bread

A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? a. turn the client from side to side b. elevate the height of the dialysate bag c. lower the head of the client's bed d. advance the catheter approximately 2.5 cm further

a. turn the client from side to side

A nurse is providing discharge instructions to a client who is postoperative following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a mole's potential malignancy? a. ulceration b. blanching of surrounding skin c. dimpling d. fading of color

a. ulceration ulceration, bleeding, and exudation are indications of a mole's potential malignancy. increasing size is also a warning sign. the nurse emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month.

A nurse is assessing a client who has urolithiasis and reports pain in his thigh. This findings indicates the stone is in which of the following structures a. ureter b. bladder c. renal pelvis d. renal tubules

a. ureter when stones are in the ureters, pain radiates to the genitalia and to the thighs

A nurse is caring for a client who had a fiberglass cast placed on her left arm several hours ago and now reports itching under the cast. Which of the following actions should the nurse plan to take? a. use a hair dryer on a cool setting to blow air into the cast b. ask the provider to bivalve the cast c. provide the client with a sterile cotton swab to rub the affected skin d. wrap the extremity with a dry heating pad

a. use a hair dryer on a cool setting to blow air into the cast the nurse should provide relief for this client's itching by blowing air into the cast using a hair dryer on a cool setting or an empty 60 mL plunger syringe

a nurse is planning to administer pain medication to a client following abdominal surgery. which of the following actions should the nurse take first? a. use the pain scale to determine the client's pain level b. discuss the adverse effects of pain medication with the client c. obtain the client's vital signs d. check the client's allergies

a. use the pain scale to determine the client's pain level

A nurse is caring for a client who is scheduled to receive peritoneal dialysis. Which of the following actions should the nurse take? a. warm the dialysate solution prior to administration b. cleanse the catheter site using a back and forth motion, beginning at the end of the catheter and moving inward c. place the drainage bag at the level of the client's chest d. apply clean gloves and cleanse the client's catheter site with cold water

a. warm the dialysate solution prior to adminsitration

A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove the client's meal tray? a. wheat toast b. tapioca pudding c. hard-boiled egg d. mashed potatoes

a. wheat toast

A nurse is assessing a client who sustained a recent head injury. Which of the following injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? a. widened pulse pressure b. tachycardia c. periorbital edema d. decrease in urine output

a. widened pulse pressure

a nurse is caring for a client with premenstrual disorder (PMD) who has a prescription for fluoxetine. the client asks the nurse, when should I notice the benefits of this medication? which of the following responses should the nurse take? a. you should expect decreased manifestations within a few days b. manifestations decrease after about 2 months c. you should expect decreased manifestations immediately. d. manifestations will decrease after several weeks

a. you should expect decreased manifestations within a few days.

A nurse is providing teaching about lifestyle changes to a client who experienced a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching? a. "I should eat foods that are high in saturated fat." b. "Before taking my medication, I will count my radial pulse rate." c. "I will exercise once a week for an hour at the health club." d. "I will stop taking my medication when my blood pressure is within a normal range."

b. "Before taking my medication, I will count my radial pulse rate." A beta blocker will induce bradycardia. The client should take the pulse rate for 1 minute before self-administration

A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching? a. "Place a warm compress on your forehead." b. "Darken the lights." c. "Light a scented candle." d. "Drink a caffeinated beverage."

b. "Darken the lights."

A nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2 g sodium diet. Which of the following statements by the client indicates an understanding of the teaching? a. "I should use salt sparingly while cooking." b. "I can have yogurt as a dessert." c. "I should use baking soda when I bake." d. "I should use canned vegetables instead of frozen."

b. "I can have yogurt as a dessert." the client understands the teaching when he selects yogurt as a dessert. yogurt is low in fat and sodium and is a good source of calcium and protein

A female client who has recurrent cystitis asks the nurse about preventing future episodes. For which of the following client statements should the nurse provide further teaching? a. "I drink at least 2 L of fluid per day." b. "I prefer taking tub baths to showering" c. "I urinate before and after sexual intercourse d. "I wipe from front to back after urinating."

b. "I prefer taking tub baths to showering."

A nurse is teaching a client who is on bed rest about preventing complications. Which of the following client statements indicates an understanding of the teaching? a. "I should perform range-of-motion exercises once per day." b. "I should cough and deep-breathe every hour." c. "I should change my position every 4 hours." d. "I should perform foot and ankle pumps every 3 hours."

b. "I should cough and deep-breathe every hour."

A nurse is providing discharge teaching to a client following an open radical prostatectomy. The client is going home with an indwelling urinary catheter. Which of the following statements by the client indicates and understanding of the teaching? a. "I will be able to take a tub bath in 1 week." b. "I will change drainage bag once each week." c. "I will use suppositories to prevent constipation." d. "I will regain my bladder control once the catheter is removed."

b. "I will change the catheter drainage bag once each week." the nurse should teach the client to change the catheter drainage bag and explain the importance of changing the bag at least once each week.

A nurse is reaching a client who has an amputation of the left lower leg 3 days ago. Which of the following statements indicates that the client understands how to care for the incision and his left upper leg? a. "I should use powder inside my limb sock to keep it cool." b. "I will lie on my stomach for 30 min a few times a day." c. "I should expect some drainage with a strong odor because I had gangrene." d. "I will keep elevating my leg on 2 pillows to keep the swelling down."

b. "I will lie on my stomach for 30 min a few times a day." the client should lie prone 3 or 4 times per day for 20-30 min. this position will help reduce the risk of developing hip flexion contractures

A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching? a. "I will use a soft toothbrush or foam swab for oral care" b. "I will use lemon and glycerin swabs after meals" c. "I will remove my dentures except while eating" d. "I will rinse my mouth frequently with hydrogen peroxide solution"

b. "I will use lemon and glycerin swabs after meals"

A nurse is providing post-procedural teaching to a client who had a diagnostic knee arthroscopy. Which of the following statements indicates that the client understand the nurse's instructions? a. "I'll take aspirin to relieve my pain." b. "I'll keep my leg elevated for the first day." c. "I'll put a heating pad on my knee for the first day." d. "I'll resume my usual activities as soon as I leave."

b. "I'll keep my leg elevated for the first day."

A nurse is preparing a client who is scheduled to have an arthroscopy the following day. Which of the following statements indicates that the client understands the pre-procedure teaching? a. "I'll have to keep my leg straight throughout the whole procedure." b. "The doctor will be able to see if I have signs of rheumatoid arthritis." c. "I should expect to stay overnight until I can walk around." d. "I'll have a scar that will be about an inch long."

b. "The doctor will be able to see if I have signs of rheumatoid arthritis." an arthroscopy helps with diagnosing musculoskeletal disorders such as rheumatoid arthritis, osteoarthritis, and internal joint injuries

A nurse is providing teaching about exercise to a client who has type 1 diabetes mellitus. Which of the following statements should the nurse include? a. "You should exercise during a peak insulin time." b. "Wear a medical alert identification tag when you exercise." c. "Exercise can decrease the effects of insulin and cause your blood glucose levels to increase." d. "You will get the most benefit from exercise when your glucose levels are higher than normal."

b. "Wear a medical alert identification tag when you exercise."

A nurse is teaching a female client who has pyelonephritis about the disorder. Which of the following pieces of information should the nurse include to help the client prevent a recurrence? a. "Douche after vaginal intercourse." b. "Wipe from front to back after defecation." c. "Avoid foods that are high in phosphate." d. "Add yogurt to your diet regularly."

b. "Wipe from front to back after defecation."

A nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine cancer. Which of the following pieces of information should the nurse include in the teaching? a. "You will need to continue to use some form of birth control for 6 months." b. "You might experience manifestations of menopause." c. "Do not lift anything heavier than 15 lb." d. "Pain or burning with urination is an expected outcome of this surgery."

b. "You might experience manifestations of menopause."

A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? a. "You can expect your vision to return immediately after the procedure." b. "You should avoid reading for 1 week." c. "You can remove eye shields when you're sleeping." d. "You should not lift objects that weigh more than 25 lb."

b. "You should avoid reading for 1 week."

A nurse is preparing a client for an electroencephalogram. Which of the following pieces of information should the nurse share with the client? a. "Expect the test to take about 3 hr." b. "You'll begin by lying still with your eyes closed." c. "You'll sleep for the duration of the procedure." d. "Expect some mild electrical shocks during the test."

b. "You'll begin by lying still with your eyes closed."

A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, which of the following responses should the nurse provide? a. "you need to conserve energy at this time." b. "lying quietly in bed helps slow down the activity in your intestines." c. "staying in bed promotes the rest and comfort you need." d. "staying in bed will help prevent injury and minimize your fall risk."

b. "lying quietly in bed helps slow down the activity in your intestines." the greatest risk to the client is complications from severe diarrhea such as dehydration, electrolytes imbalances, and gastrointestinal bleeding and trauma. activity restriction can help reduce intestinal peristalsis and diarrhea

A nurse is teaching a client who has a vaginal hysterectomy with a bilateral oophorectomy. Which of the following pieces of information should the nurse include in the teaching? a. "plan to use some type of birth control for up to 6 weeks after surgery." b. "use a water-based lubricant when having sexual intercourse." c. "expect to have an increase in bloody vaginal drainage during the first 10 days after surgery." d. "plan to start some type of aerobic exercise such as swimming within a week after surgery."

b. "use a water-based lubricant when having sexual intercourse." vaginal dryness is a manifestation of menopause after the ovaries are removed. the client may require a water-based lubricant when having sexual intercourse

A nurse is providing discharge teaching to the partner of a client who has acquired immune deficiency syndrome. Which of the following statements by the client's partner indicates a need for further teaching? a. "I will dispose of soiled tissues in separate plastic bags." b. "I'll clean up blood spills immediately with hot water." c. "I know that handwashing is an important preventative measure." d. "I will wash soiled clothes in hot water

b. 'I'll clean up blood spills immediately with hot water."

A nurse is presenting an in-service training session about nutrition. How many of the amino acids must be obtained from dietary intake? a. 6 b. 9 c. 11 d. 15

b. 9 Proteins are made up of chains of amino acids, which are composed of carbon, hydrogen, oxygen, and nitrogen. 9 amino acids are considered essential for the human body and must be obtained from diet. These include histidine, isoleucine, leucine, methionin, phenylalanine, threonine, tryptophan, and valine.

A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? a. orthopnea b. Cheyne-stokes c. paradoxical d. Kussmaul

b. Cheyne-stokes Cheyne-stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. Cheyne-stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death

A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever, chills, fatigue, and pallor over the past week. When checking the client's laboratory results, which of the following values should the nurse identify as contributing to the client's fatigue and pallor? a. magnesium 2 b. HgB 6.5 c. WBC 9.6 d. creatinine 0.8

b. Hgb 6.5

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? a. excessive airway secretions b. a leak within the ventilator's circuitry c. decreased lung compliance d. the client coughing or attempting to talk

b. a leak within the ventilator's circuitry

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? a. excessive airway secretions b. a leak within the ventilator's circuity c. decreased lung compliance d. the client coughing or attempting to talk

b. a leak within the ventilator's circuity the low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator

A nurse is performing an admission assessment for a client who has colorectal cancer. Which of the following manifestations should the nurse expect to find? a. hematuria b. abdominal cramps c. weight gain d. polycythemia

b. abdominal cramps Clients who have colorectal cancer are likely to have changes in bowel habits, occult blood in the stool, weight loss, fatigue, and "gas pains" or abdominal cramping

a nurse is evaluating how a client who is pregnant is responding to a medication. which of the following physiological effects of pregnancy should the nurse take into consideration? a. increased intestinal transit rate b. accelerated excretion of fluids c. reduced renal blood flow d. decreased hepatic metabolism

b. accelerated excretion of fluids

A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? a. zoster vaccine b. acyclovir c. amoxicillin d. infliximab

b. acyclovir the nurse should anticipate a prescription for acyclovir, an antiviral medication that inhibits replication of the virus that causes herpes zoster

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? a. eliminating environmental triggers that precipitate attacks b. addressing the client's perception of the disease process and what might have triggered past attacks c. overviewing the client's medication regimen d. explaining manifestations of respiratory infections

b. addressing the client's perception of the disease process and what might have triggered past attacks

a nurse on a telemetry unit is caring for a client who had a myocardial infarction. the client states "all this equipment is making me nervous." which of the following responses should the nurse make? a. you won't need the equipment for very long b. all of this equipment can be frightening c. why does the equipment bother you? d. let me tell you about what each machine does

b. all of this equipment can be frightening

A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's effected extremity? a. absent pedal pulses b. ankle swelling c. hair loss d. skin atrophy

b. ankle swelling the nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. other manifestations can include brown pigmentations and cellulitus

A nurse is caring for a client who has platelet count of 50,000/mm^3. After discontinuing the client's peripheral IV site. Which of the following actions should the nurse take? a. apply warm compresses b. apply pressure to the catheter removal site for 5 min c. place the affected arm in a dependent position d. clean the insertion site with alcohol

b. apply pressure to the catheter removal site for 5 min A platelet count below 100,000/mm^3 indicates thrombocytopenia, which puts the client at an increased risk of bleeding. By applying pressure to the site for at least 5 minutes, the nurse promotes coagulation and prevents additional blood loss

A nurse is caring for a client who has received sedation when the nurse applies nailbed pressure, the client withdraws his hand. The nurse should document this response as indicating which of the following? a. confusion b. arousal c. orientation d. attention

b. arousal the nurse should document that the client is demonstrating some degree of arousal. Withdrawing the hand in response to nailbed pressure indicates responsiveness to sensory stimulation

A nurse is planning dietary teaching dietary teaching for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? a. obtain sample menus from the dietician to give to the client b. ask the client to identify the types of foods she prefers c. identify the recommended range of the client's blood glucose level d. discuss long-term complications that can result from non-adherence to the dietary plan

b. ask the client to identify the types of foods she prefers

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse take? a. elevate the residual limb on a soft pillow b. assist the client into a prone position ever 4 hr c. re-apply a bandage to the residual limb every 12 hr d. apply dressings to the site in a proximal-to-distal direction

b. assist the client into a prone position every 4 hr

A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? a. A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? a. P waves occurring at 0.16 seconds before each QRS complex b. atrial rate of 300/min with QRS complex of 80/min c. ventricular rate of 82/min with an atrial rate of 80/min d. irregular ventricular rate of 125/min with a wide QRS pattern

b. atrial rate of 300/min with QRS complex of 80/min

A nurse is teaching a client about urinary tract infections (UTIs). Which of the following manifestations should the nurse include? a. weight gain b. back pain c. vaginal discharge d. muscle cramps

b. back pain Back pain, and flank pain are manifestations of a UTI. Other manifestations include frequency, urgency, and cloudy, foul-smelling urine

A nurse in a provider's office is assessing a client who has GERD. WHen documenting the client's history, the nurse should expect the client to report that symptoms worsen with which of the following actions? a. stair-climbing b. bending over c. sitting d. walking

b. bending over GERD symptoms are most evident with activities that increase intraabdominal pressure

A nurse is preparing an older adult client who had a transient ischemic attack for discharge. The nurse should teach the client to monitor which of the following parameters at home? a. blood glucose b. blood pressure c. daily weight d. sensation in the feet

b. blood pressure

A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse teach the client to perform? (select all that apply) a. use antimicrobial ointment on the peristomal skin b. empty the bag when it is one-third to one-half full c. cut the skin barrier opening a little larger than the ostomy d. wash the peristomal skin with mild soap and water e. apply the skin barrier while the skin is slightly moist

b. c. d.

A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (select all that apply) a. hypothyroidism b. hypertension c. diabetes mellitus d. hyperlipidemia e. tobacco smoking

b. c. d. e.

A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following acting should the nurse take? (select all that apply) a. place the client in respiratory isolation b. monitor vital signs every 2 hr c. assess neurological status every 4 hr d. maintain the client in a modified Trendelenburg position e. keep the client's room darkened

b. c. e.

A nurse is assessing a disseminated intravascular coagulation in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (select all that apply) a. bradycardia b. bleeding at the venipuncture site c. petechiae on the chest and arms d. flushed, dry skin e. abdominal distention

b. c. e. the formation of large amounts of microemboli in the circulation depletes the body's platelets and clotting factors. as a result, uncontrollable bleeding can occur, as manifested by bleeding at the venipuncture site, petechiae on the chest and arms, and bleeding in the abdominal cavity resulting in abdominal distention due to internal bleeding

A nurse in a emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? a. estimation of burn injury b. characteristics of the cough and sputum c. extent of peripheral edema d. amount of urine output

b. characteristics of the cough and sputum

A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? a. estimation of burn injury b. characteristics of the cough and sputum c. extent of peripheral edema d. amount of the urine output

b. characteristics of the cough and sputum

A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first? a. administer an analgesic to the client b. check the client's electrolyte values c. measure the client's weight d. restrict the client's protein intake

b. check the client's electrolyte values

A nurse is planning care for a client who has Cushing's syndrome due to chronic corticosteroid use. Which of the following actions should the nurse include in the plan of care? a. check the client's blood glucose for hypoglycemia b. check the client's urine specific gravity c. weight the client weekly d. insert an indwelling urinary catheter for the client

b. check the client's urine specific gravity

A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? a. depressed fracture of the forehead b. clear fluid coming from the nares c. motor loss on one side of the body d. bleeding from the top of the scalp

b. clear fluid coming from the nares

A nurse is caring for a client who has Meniere's disease. The nurse should identify that Meniere's disease affects which structure of the ear? a. eustachian tube b. cochlea c. perichondrium d. eardrum

b. cochlea Meniere's disease is a condition of the inner ear in which excess fluid distorts the inner ear canal system. this distortion decreases hearing via dilation of the cochlear duct, leading to vertigo from damage to the vestibular system

A nurse is preparing an in-service presentation about the basics of bone injuries. Which of the following types of fractures results when a client's bone breaks into multiple pieces? a. avulsion b. communited c. compression d. spiral

b. communited

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? a. pitting edema b. crackles in the lung bases c. jugular vein distention d. hepatomegaly

b. crackles in the lung bases left-sided heart failure precipitates pulmonary congestion and edema, causing crackles in the lungs

A nurse in a provider's office is reviewing the medical records of a group of clients. Which of the following clients is at risk for iron deficiency? (select all that apply) a. a client who is postmenopausal b. a client who is vegetarian c. a middle adult male client d. a client who is pregnant e. a toddler who is overweight

b. d. e

A nurse is preparing a client for a bone scan. Which of the following statements indicates that the client understands the pre-procedure teaching? (select all that apply) a. "I will have to drink a radioactive solution before the test begins." b. "A special camera will scan the bones in my entire body." c. "There will be better absorption of the radiation by healthy bone." d. "I'll have to drink a lot of water to help get the radiation out of my body." e. "I understand the radiation is harmless, and I don't have to worry about it."

b. d. e.

A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? (select all that apply) a. insert a 23-gauge angiocatheter with an IV adaptor b. check to determine the packed RBCs are less 1 week old c. ask another nurse to check the packed RBCs label against the medical record e. prime the transfusion tubing with 0.9% sodium chloride

b. d. e.

A nurse is teaching a client who has diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include? (select all that apply) a. bradycardia b. diaphoresis c. deep, rapid respirations d. palpitations e. shakiness

b. d. e.

A nurse is assessing an older adult client for physiological changes that can occur with age. Which of the following findings should the nurse expect? a. increased saliva production b. decreased sense of taste c. increased sense of smell d. decreased chest wall rigidity

b. decreased sense of taste when assessing an older adult client, the nurse should expect a decreased sense of taste due to atrophy of the taste buds

A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect? a. Kussmaul respirations b. diaphoresis c. decreased skin turgor d. ketonuria

b. diaphoresis a client who has a blood glucose level below 70 mg/dL will exhibit manifestations of hypoglycemia. expected findings associated with hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness, and confusion

A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemispheric stroke. Which of the following findings should the nurse expect? a. reduced left-sided motor funciton b. difficulty with speech c. impulsive behavior d. neglect of the left side of the body

b. difficulty with speech

A nurse is preparing an in-service presentation about the management of myocardial infarction. Death following MI is often a result of which of the following complications? a. cardiogenic shock b. dysrhythmias c. heart failure d. pulmonary edema

b. dysrhythmias according to evidence-based practice, dysrhythmias are the most common cause of death following MI. therefore, nurses should monitor client's ECGs carefully for dysrhythmias and report and treat them immediately

A nurse is planning care for a client who is postoperative following a gastrectomy. Which of the following strategies should the nurse include to help prevent dumping syndrome? a. have the client drink plenty of water with meals b. eliminate simple sugars and sugar alcohols from the client's diet c. limit the client's intake to 2 meals per day d. offer the client meals that are low in protein or protein-free

b. eliminate simple sugars and sugar alcohols from the client's diet

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? a. place the drainage bag on the client's abdomen when transferring from a bed to cart b. empty the drainage bag when half-full of urine c. rest the drainage bag on the floor when closing the drainage spigot during emptying d. disconnect the drainage bag when obtaining a urine specimen

b. empty the drainage bag when half-full of urine

A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4hr ago. Which of the following actions should the nurse take? a. inspect the client's skin underneath the boot every 12 hr b. encourage the client to perform dorsiflexion of the affected extremity every 2hr c. remove the weights from the traction while repositioning the client in bed d. loosen the ropes if the client reports muscle spasms is the affected extremity

b. encourage the client to perform dorsiflexion of the affected extremity every 2hr the nurse should encourage the client to perform dorsiflexion of the affected extremity every 2 hours to assess if the client is experiencing nerve damage. weakness of dorsiflexion can indicate peroneal nerve damage. if this occurs, the nurse should notify the provider immediately

A nurse in an oncology clinic is assessing a client who has early stage hodgkin's lymphoma. Which of the following findings should the nurse expect? a. bone and joint pain b. enlarged lymph nodes c. intermittent hematuria d. productive cough

b. enlarged lymph nodes

A nurse is teaching a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues? a. subcutaneous b. epidermis c. dermis d. stratum corneum

b. epidermis Basal cell carcinoma originates from the epidermal layer of the skin. It is the most common form of skin cancer

the nurse is caring for an older adult client who has an in-the-canal hearing aid. the. client states that the hearing aid is making a whistling sound. the nurse should identify which of the following factors as the source of this sound? a. low battery power b. excessive wax is in the ear canal c. a volume setting that is too low d. a crack in the ear tube

b. excessive wax in the ear canal

A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures of his tibia, unla, and several ribs. The client is now disoriented to time and place and has a SaO2 of 87%. The nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse expect? a. hypovolemic shock b. fat embolism syndrome c. thrombophlebitis d. avascular bone necrosis

b. fat embolism syndrome

A nurse is teaching a client about preventing the transmission of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes? a. maternal-fetal b. fecal-oral contamination c. genital sexual contact d. blood to blood

b. fecal-oral contamination Hepatitis A is most commonly transmitted by the fecal-oral route, usually through ingesting food or liquid that has been infected with the virus. Outbreaks from contaminated food are usually due to poor hygiene practices by food handlers or shellfish sourced from contaminated water

A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect? a. excessive salivation b. finger contractures c. periorbital edema d. alopecia

b. finger contractures Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs.

A nurse is providing dietary teaching to a client who has chronic renal failure. Which of the following food choices by the client indicates an understanding of the teaching? a. canned soup b. grilled fish c. pastrami d. peanut butter

b. grilled fish

A nurse is caring for a client who is in skeletal traction following a femur fracture. On entering, the nurse finds that the client has slid toward the foot of the bed, and the traction weight is resting on the floor. Which of the following actions should the nurse take? a. remove the weight temporarily to reposition the client to the correct alignment in bed b. have the client use a trapeze to pull himself up while ensuring the weight hangs freely c. lift the rope off the pulley while the client rocks back and forth to reposition himself d. lift the weight manually while another staff member moves the client up in bed

b. have the client use a trapeze to pull himself up while ensuring the weight hands freely

A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require which of the following treatments? a. an assistive device when the client is ambulating b. heat paraffin therapy applied to the client's joints c. gentle massage of the client's hands d. active range-of-motion exercises on the client's affected joints

b. heat paraffin therapy applied to the client's joints

A nurse is assessing a client who was brought to the emergency department following a motor-vehicle crash. Which of the following findings is a manifestation of bladder trauma? a. stress incotinence b. hematuria c. pyuria d. fever

b. hematuria

a nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. which of the following pieces of information should the nurse include in the teaching? a. exhale slowly to reach the goal volume b. hold the breath for 5 sec after goal volume is reaches c. continue to breathe deeply between each cycle d. limit the repeat pattern of breathing to 5 breaths

b. hold the breath for 5 sec after goal volume is reached

A nurse is caring for a client who has been diagnosed with an addisonian crisis and has a blood pressure of 74/42 mmHg. Which of the following prescriptions should the nurse anticipate? a. desmopressin b. hydrocorticone c. dopamine d. furosemide

b. hydrocortisone

A nurse is reviewing the laboratory report of a client who has chronic kidney disease. The nurse finds the following laboratory test results: potassium 6.8, calcium 7.4, hemoglobin 10.2, and phosphate 4.8. Which finding is the priority for the nurse to report to the provider? a. hypocalcemia b. hyperkalemia c. anemia d. hypoalbuminemia

b. hyperkalemia The nurse should apply the urgent versus nonurgent priority-setting framework when caring for this client

A nurse is caring for a client who has chronic glomerulonephritis with oliguria. For which of the following electrolyte imbalances should the nurse monitor? a. hypercalcemia b. hyperkalemia c. hypomagnesemia d. hypophosphatemia

b. hyperkalemia oliguria resulting from chronic glomerulonephritis causes potassium retention, leading to levels above the expected reference range of 3.5 to 5 mEq/L. Other electrolyte imbalances common with this disorder affect sodium and phosphorus levels. Chronic glomerulonephritis eventually leads to end-stage kidney disease

A nurse is conducting a home visit for an older adult client who has diabetes mellitus and takes regular insulin subcutaneously before each meal. The client appears disoriented and weak and has slurred speech. Which of the following conditions should the nurse consider first when responding to these manifestations? a. dementia b. hypoglycemia c. infection d. transient ischemic attack

b. hypoglycemia

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? a. increased cardiac output b. increased pulmonary congestion c. decreased left atrial pressure d. decreased pulmonary artery pressure

b. increased pulmonary congestion pulmonary congestion is a manifestations of mitral vale stenosis. because of the defect in the mitral valve, the left atrial pressure rises and the left atrium dilates. the increased pressure results in a backflow of blood from the left atrium through the pulmonary vein and into the lungs resulting in pulmonary congestion

A nurse is caring for a client who has type 2 diabetes mellitus and is displaying manifestations of hyperglycemia. Which of the following findings indicates the client has hyperglycemia? a. hunger b. increased urinartion c. cold, clammy skin d. tremors

b. increased urination Increased urination is a manifestation of hyperglycemia due to a deficiency of insulin, which can lead to osmotic diuresis

A nurse is caring for a client who has type 2 diabetes mellitus and is displaying manifestations of hyperglycemia. Which of the following findings indicates the client has hyperglycemia? a. hunger b. increased urination c. cold, clammy skin d. tremors

b. increased urination increased urination is a manifestation of hyperglycemia due to a deficiency of insulin, which can lead to osmotic diuresis

A nurse is assessing a client who is 12 hr postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the provider? a. hypoactive bowel sounds b. indwelling urinary catheter output 25 mL/hr c. heart rate of 96/min d. serous drainage at the surgical incision site

b. indwelling urinary catheter output 25 mL/hr the nurse should report a urinary output of less than 30 mL/hr to the provider, as this can indicate hypovolemia

A nurse is assessing a client who is 12hr postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the provider? a. hypoactive bowel sounds b. indwelling urinary catheter output of 25 mL/hr c. heart rate of 96/min d. serous drainage at the surgical site

b. indwelling urinary catheter output of 25 mL/hr the nurse should report a urinary output of <30 mL/hr to the provider, as this can indicate hypovolemia or renal complication

A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene? a. visualizing the eardrum before irrigating b. instilling 50 mL of fluid with each irrigation c. using firm, continuous pressure while irrigating d. warning the irrigation fluid to least 37

b. instilling 50 m: of fluid with each irrigation

a community health nurse is visiting the home of an older adult client & her caregiver. the client has excoriations to her wrists & ankles. which of the following actions should the nurse take first? a. refer the caregiver to a support group b. interview the client in private c. document the client's wounds d. contact adult protective services

b. interview the client in private

A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the nurse expect? a. elevated blood pressure b. involuntary muscle spasms c. cold intolerance d. weight loss

b. involuntary muscle spams 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 paresthesia's can result due to decreased parathyroid hormone levels and calcium deficiency

A nurse is planning an in-service training session regarding nutrition. Which of the following minerals should the nurse identify as involved in oxygen transportation? a. zinc b. iron c. phosphorus d. magnesium

b. iron

a nurse is assessing an older adult client for age-related changes. which of the following should the nurse identify as an age-related physical change? a. prolonged hypotension b. loss of ventricular compliance c. increased loose stools & diarrhea d. decreased response to diuretics

b. loss of ventricle compliance

A nurse is assisting a provider with a comprehensive physical examination of a client when the provider uses transillumination, the nurse should explain to the client that this technique helps evaluate which of the following structures? a. lymph nodes b. maxillary sinuses c. intercostal spaces d. salivary glands

b. maxillary sinuses Transillumination is a procedure that allows the passage of light, often bright halogen light, through body tissues. Occluded sinuses prevent the passage of light rays through the sinus air sacs. Clear sinus air spaces allow transillumination

A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care? a. restrict fluids to 1,000 mL per day b. measure the client's abdominal girth daily c. check the IV sites every 4 hr for bleeding d. administer an enema as needed for constipation

b. measure the client's abdominal girth daily the nurse should measure the client's abdominal girth daily to monitor for manifestations of internal bleeding. a client who has reduced platelet count is at risk of bleeding due to delayed clotting.

A nurse is planning a community health screening for a group of clients who are at risk for type 2 diabetes mellitus. Which of the following clients should the nurse include in the screening? a. men who smoke b. men and women who are obese c. women who have hepatitis d. ment and women who consume high-protein and low-carbohydrate foods

b. men and women who are obese

a nurse is reinforcing teaching with a newly licensed nurse about contraindications to vaccines. which of the following examples should the nurse provide as a true contraindication for all vaccines? a. previous local reaction to an injectable vaccine b. moderate illness without fever c. recent exposure to an infectious disease d. family history of an allergy to penicillin

b. moderate illness without fever

A nurse is examining the ECG of a client who has frequent premature ventricular contractions. Which of the following QRS changes should the nurse expect to see on the client's ECG? a. narrower than usual QRS complexes b. much greater amplitude than the usual QRS complexes c. same polarity as the usual QRS complexes d. immediate resumption of the usual rhythm

b. much greater amplitude than the usual QRS complexes

a nurse is providing teaching to a client who has type 2 diabetes mellitus & a new prescription for metformin. which of the following adverse effects of metformin should the nurse instruct the client to watch for & report to the provider a. weight gain b. myalgia c. hypoglycemia d. severe constipation

b. myalgia

A nurse is caring for a male client who reports a thick urethral discharge. Which of the following actions should the nurse take? a. contact the client's sexual partners b. obtain a urethral specimen for culture c. prepare to administer penicillin to the client d. obtain blood for a rapid plasma reagin test

b. obtain a urethral specimen for culture

A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? a. pupils nonreactive to light b. opacity visible behind the pupil c. white circle around the outside border of the iris d. increased intraocular pressure

b. opacity visible behind the pupil with a cataract, the lens of the eye becomes thick and opaque with age and appears as opacity behind the pupil when the nurse shines a light on the area

A nurse is planning care for a client who has cancer and has developed thrombocytopenia following chemotherapy. Which of the following precautions should the nurse offer to minimize the adverse effects of thrombocytopenia? a. monitor visitors for manifestations of infection b. remind the client to use an electric razor c. encourage frequent rest periods d. instruct the client to rinse mouth daily with normal saline

b. remind the client to use an electric razor

A nurse is caring for a client immediately following application of a plaster cast. The nurse should monitor for a report which of the following findings as an indication of compartment syndrome? a. sensation of heat on the surface of the cast b. paresthesia of the extremity c. pruritus of the extremity d. musty odor noted from cast materials

b. paresthesia of the extremity the nurse should identify paresthesias as a findings of compartment syndrome. compartment syndrome involves the compression of nerves and blood vessels in an enclosed space, leading to impaired blood flow and nerve damage

a nurse is teaching a client who has persistent cancer pain about the adverse effects of opioids. which of the following statements should the nurse include in the teaching? a. opioids do not relieve pain without causing severe adverse effects b. physical dependence is not the same thing as addiction c. tolerance typically means the medication will no longer be effective d. the most common adverse effect is respiratory depression with prolonged use

b. physical dependence is not the same as addiction

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? a. cadaver skin b. pig skin c. amniotic membranes d. beef collagen

b. pig skin Heterografts are obtained from an animal, usually a pig

A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next? a. administer nifedipine b. place the client in a high-fowler's position c. check for urinary retention d. check for a fecal impaction

b. place the client in high-fowler's position according to evidence-based practice, the nurse should first place the client in a high-fowler's position to decrease the client's blood pressure and reduce the risk of end-organ damage from the sudden rise in blood pressure

A nurse is assessing a client who is receiving a continuous ambulatory peritoneal dialysis. Which of the following findings should the nurse report to the provider? a. WBC 6,000/mm^3 b. potassium 3.0 mEq/L c. clear, pale, yellow drainage d. report of abdominal fullness

b. potassium 3.0 mEq/L a potassium level of 3.0 mEq/L is below the expected reference range and can cause dysrhythmias. dialysis removes fluid, waste products, and electrolytes from the blood and can cause hypokalemia

A nurse is assessing a client who is recovering from a thyroidectomy and has a harsh, high-pitched respiratory sound. Which of the following actions should the nurse take? a. hyperextend the client's neck b. prepare for a tracheostomy c. lower the head of the bed d. administer morphine

b. prepare for a tracheostomy the nurse should notify the provider immediately and prepare for a tracheostomy. laryngeal stridor is a high-pitched, harsh breathing sound that indicates respiratory distress due to swelling, tetany, or laryngeal spasms

A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? a. Obtain blood samples to test platelet function b. prepare for replacement of the missing clotting factor c. administer aspirin for the client's pain d. place the bleeding joint in the dependent position

b. prepare for replacement of the missing clotting factor

A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? a. obtain blood samples to test platelet function b. prepare for replacement of the missing clotting factor c. administer aspirin for the client's pain d. place the bleeding joint in the dependent position

b. prepare for replacement of the missing clotting factor hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. Aggressive factor replacement is initiated to prevent hemarthrosis, which can result in a long-term loss of range of motion in repeatedly affected joints

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? a. flattened T waved b. prolonged QT intervals c. shortened QT intervals d. widened QRS complexes

b. prolonged QT intervals manifestation oh hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. causes hypoparathyroidism, chronic kidney disease, and diarrhea

A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease with emphysema. This breathing technique accomplishes which of the following? a. increases oxygen intake b. promote carbon dioxide elimination c. uses the intercostal muscles d. strengthens the diaphragm

b. promote carbon dioxide elimination a client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. this simple method slows the client's pace of breathing, making each breath more effective. pursed-lip breathing releases trapped air in the lungs and prolongs exhalation in order to slow the breathing rate. this improved breathing patter moves carbon dioxide out of the lungs more efficiently

A nurse is planning a presentation at a community center about risk factors for cancer. Which of the following types of cancer should the nurse include when discussing familial clustering of specific types of cancer? a. skin b. prostate c. bone d. bladder

b. prostate Types of cancers that typically demonstrate a familial tendency include breast, colorectal, ovarian, and prostate

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure? a. reorient the client b. protect the client's head c. loosen constrictive clothing d. turn the client onto his side

b. protect the client's head

a nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. which of the following should the nurse include in the plan of care? Select all that apply. a. set the suction machine at 120 mmHg b. provide oral hygiene frequently c. measure the amount of drainage from the NG tube every shift d. secure the NG tube to the client's gown e. apply petroleum jelly to the client's nares

b. provide oral hygiene frequently c. measure the amount of drainage from the ng tube every shift d. secure the ng tube to the client's gown

A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is O-negative. Which of the following actions should the nurse take? a. continue to monitor for manifestations of a transfusion reaction b. remove the unit of plasma immediately and start an IV infusion of normal saline solution c. continue the transfusion and repeat the type and crossmatch d. prepare to administer a dose of diphenhydramine IV

b. remove the unit of plasma immediately and start an IV infusion of normal saline solution

A nurse is caring for a client who has a brainstem injury. Which of the following physiological functions should the nurse monitor? a. understanding speech b. respiratory effort c. decision-making ability d. temperature control

b. respiratory effort The nurse should monitor the respiratory effort of a client who has an injury to the brainstem. The medulla in the brainstem controls the respiratory center

A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a "flash" of light followed by a "curtain" across the field of vision/ The nurse should identify that these manifestations indicate which of the following disorders? a. glaucoma b. retinal detachment c. macular degeneration d. cataracts

b. retinal detachment

A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation. Which of the following actions should the nurse take? a. place the client on a soft mattress b. rewrap the residual limb with a bandage 3 times per day c. assist the client into a prone position for 20 min every 8 hr daily d. turn the client every 4 hr while in bed

b. rewrap the residual limb with a bandage 3 times per day

A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following laboratory values can indicate arthritis? a. reticulocyte count b. rheumatoid factor c. direct coombs' test d. platelet count

b. rheumatoid factor

A nurse is providing dietary teaching to a client who has ulcerative colitis. Which of the following foods selections by the client indicates an understanding of the teaching? a. raw vegetable salad with low-fat dressing b. roast chicken and white rice c. fresh fruit salad and milk d. peanut butter on whole wheat bread

b. roast chicken and white rice clients who have ulcerative colitis are restricted to a low-fiber diet, which omits whole grains and raw fruits and vegetables. roast chicken with white rice is the best choice

A nurse is providing a dietary teaching to a client who has ulcerative colitis. Which of the following food selections by the client indicates an understanding of the teaching? a. raw vegetable salad with low-fat dressing b. roast chicken and white rice c. fresh fruit salad and milk d. peanut butter on whole wheat bread

b. roast chicken and white rice clients who have ulcerative colitis to a low-fiber diet, which omits whole grains and raw fruits and vegetables. roast chicken with white rice is the best choice

A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the following manifestations of dislocation of the hip prothesis? a. bulging in the area over the surgical incision b. shortening of the right leg c. sensation of warmth over the surgical incision d. pallor following elevation of the right leg

b. shortening of the right leg the nurse should monitor the client for shortening of the affected leg as an indication of dislocation of the prosthesis. other findings include increased hip pain, and inability to move the extremity, and rotation of the hip internally or externally

a nurse is caring for a client who has cystic fibrosis & has a prescription for high dose ibuprofen daily. the nurse should identify that which of the following is an expected outcome for the client receiving this medication? a. thinned pulmonary secretions that are retained in the airways b. slowed progression of pulmonary damage c. potentiated action of bronchodilator therapy d. decreased risk of fevers associated with CF

b. slowed progression of pulmonary damage

A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? a. hemoglobin 10 g/dL b. sodium 132 mEq/L c. albumin 3.6 g/dL d. potassium 4.0 mEq/dL

b. sodium 132 mEq/L this laboratory finding is below the expected reference range. the nurse should anticipate a low sodium level because sodium is trapped in interstitial space

A nurse is obtaining a guaiac test from a client. The test is performed to detect which of the following? a. fecal material in vomit b. blood in stool c. infestation of parasites d. microorganisms in urine

b. stool in stool

A nurse is administering a unit of packed red blood cells to a client who is postoperative. The client reports itching and hives 30 min after the infusion begins. Which of the following actions should the nurse take first? a. maintain IV access with 0.9% sodium chloride b. stop the infusion of blood c. send the blood container and tubing to the blood bank d. obtain a urine sample

b. stop the infusion of blood

a nurse is reviewing the laboratory report for a client who is taking tobramycin & notes that the peak blood level is 9.3 mcg/mL. which of the following actions should the nurse take? a. administer half of the prescribed dosage at the client's next scheduled dose b. tell the client that the medication seems to be appropriate c. advise the client to drink more water throughout the day d. ask if the client has been experiencing any peripheral neuropathy

b. tell the client that the medication seems to be appropriate

a nurse is providing nutritional teaching to a group of clients. which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching? a. the RDA is a comprehensive term that includes various dietary standards & scales b. the RDA defines the level of the nutrient intake that meets the needs of healthy people in various groups c. the RDA defines the levels of nutrients that should not be exceeded to prevent adverse health effects d. the RDA is the daily percentage of energy intake values for fat, carbohydrate, & protein.

b. the RDA defines the level of nutrients intake that meets the needs of healthy people in various groups

A nurse is evaluating the injection site of a client who had a Mantoux skin test 48 hr ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make? a. the client has active tuberculosis b. the client had an exposure to tuberculosis c. the nurse must re-evaluate the result in 24 hr d. the test is negative for tuberculosis

b. the client had an exposure to tuberculosis a Mantoux test is skin test that determines exposure to tuberculosis. the nurse should look at the test site and palpate the area to determine if the injection site is raised and feels hard to the touch. then, the nurse should record the results in millimeters to represent the size of the raised bump. redness alone does not determine a positive result

A nurse is collecting a health history from a client. Which of the following findings is the highest risk factor for the client developing bladder cancer? a. the client is a hairdresser b. the client uses tobacco c. the client is over 60 years of age d. the client has frequent urinary tract infections

b. the client uses tobacco the nurse should apply the safety and risk-reduction priority setting framework, which assigns priority tot he factor or situation posing the greatest safety risk to the client

a nurse is reviewing the medication history of a client who has asthma. which of the following medications should the nurse identify as incompatible? a. albuterol & montelukast b. theophylline & zileuton c. aminophylline & fluticasone d. salmeterol & levalbuterol

b. theophylline & zileuton

A nurse is caring for a client who has testicular cancer and is experiencing peripheral neuropathy as an adverse effect of chemotherapy. Which of the following client manifestations is an expected findings of peripheral neuropathy? a. thinning of the scalp hair b. tingling of the hands and feet c. reduced ability to concentrate d. sores in mucous membranes

b. tingling of the hands and feet

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy. The nurse should identify that this procedure is for which of the following reasons? a. to visualize polyps in the colon b. to detect an ulceration in the stomach c. to identify an obstruction in the biliary tract d. to determine the presence of free air in the abdomen

b. to detect an ulceration in the stomach an ECG is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction

A nurse is planning care for a client who has syndrome of inappropriate antidiuretic syndrome with mild manifestations. The nurse should expect the provider to prescribe which of the following medications? a. chlorpropamide b. tolvaptan c. vasopressin d. desmopressin

b. tolvaptan SIADH is a disorder of water intoxication due to the inappropriate continuous secretion of antidiuretic hormone by the posterior pituitary gland, causing hypervolemia and hyponatremia. Treatment of SIADH include fluid restriction, sodium replacement with small amounts of 0.9% sodium chloride, and vasopressin antagonist such as tolvaptan

A nurse is walking along the unit when she sees smoke coming from the central supply room. After activating the fire alarm, which of the following actions should the nurse take? a. place unused equipment between the fire doors b. turn off sources of oxygen near the fire c. place rolled blankets at the base of the fire d. keep the doors to the unit and client rooms open

b. turn off sources of oxygen near the fire

A nurse is caring for a client who begins to have a generalized tonic-clonic seizure while lying in bed. Which of the following actions should the nurse take? a. insert an oral airway b. turn the client onto a side c. restrict movement of the client's limbs d. place a pillow under the client's head

b. turn the client onto a side The nurse should turn the client onto a side to protect the client from aspiration

A nurse is conducting dietary teaching for a client who has AIDS. Which of the following instructions should the nurse include in the teaching? a. discard leftovers after 8 hr b. use a separate cutting board for poultry c. thaw frozen foods at room temperature d. store cold foods at 10 degrees celsius or less

b. use a separate cutting board for poultry

A nurse is preparing a 24-hr urine specimen for a client who is suspected to have pheochromocytoma. Which of the following laboratory tests from the 24-hr urine specimen should the nurse use to determine the client's condition? a. creatinine clearance b. vanillylmandelic acid (VMA) c. 17-hydroxycorticosteroids d. protein

b. vanillylmandelic acids THE VMA test is used to determine if the client has pheochromocytoma, which measures the level of catecholamine metabolites in a 24-hour urine sample

A nurse is providing preoperative teaching to a client who will undergo surgery to create a temporary colostomy. The client asks the nurse about the difference between colostomies and ileostomies. Which of the following responses should the nurse make? a. "A colostomy drains stool, and an ileostomy drains urine." b. "A colostomy is temporary, and an ileostomy is permanent." c. "A colostomy is from the large intestine, and an ileostomy is from the small intestine." d. "An ileostomy requires dietary restrictions, while a colostomy does not."

c. "A colostomy is from the large intestine, and an ileostomy is from the small intestine."

A nurse is providing teaching to a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching? a. "I can keep my dentures in during the procedure." b. "I am allowed only clear liquids prior to the procedure." c. "A tissue sample might be obtained during the procedure." d. "A signed consent form is not required for this procedure."

c. "A tissue sample might be obtained during the procedure."

A nurse is teaching a newly licensed nurse about caring for a client who has a new left arteriovenous fistula. Which of the following statements should the nurse make? a. "Check the fistula site daily for a vibration." b. "Instruct the client to restrict movement of his left arm." c. "Avoid taking a blood pressure on the client's left arm." d. "Instruct the client to sleep on his left side."

c. "Avoid taking a blood pressure on the client's left arm."

A nurse is teaching a client who has tuberculosis about new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching? a. "I should take this medication with food" b. "I need to take a B-complex vitamin while using this medication" c. "I can expect this medication to turn my skin orange" d. "I can expect this medication to make my vision blurry"

c. "I can expect this medication to turn my skin orange" the nurse should instruct the client to expect the skin and urine to turn a reddish-orange color while taking rifampin

A nurse in a provider's office is teaching a client with a recent diagnosis of rheumatoid arthritis who has a new prescription for naproxen tablets. Which of the following statements by the client indicates the need for further teaching? a. "after taking this medication for 4 weeks, I'll start to notice relief in my joints." b. "I can take an antacid with this medication for indigestion." c. "I can take his medication with aspirin." d. "the naproxen goes down easier when I crush it and put it in applesauce."

c. "I can take this medication with aspirin." the nurse should instruct the client to avoid taking this medication with any other NSAIDs such as aspirin because this can increase the risk of bleeding and gastrointestinal ulceration

A home health nurse is performing an assessment on a client who is 1 week postoperative following a total knee replacement. Which of the following statements by the client indicates an understanding of the teaching? a. "I will discontinue the blood thinner my doctor prescribed once I am at home." b. "I will keep a pillow under my knee when I am in bed." c. "I plan to use a walker to help me get around." d. "I will discontinue using the CPM machine when I get home."

c. "I plan to use a walker to help me get around." the nurse should identify that the client will receive a prescription for a walker, cane, or crutches to promote ambulation following a total knee replacement

A nurse is teaching a client who was recently diagnosed with Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching? a. "I should limit my exposure to sunlight" b. "I should avoid drinking alcohol" c. "I should not smoke" d. "I should limit intake of foods that are high in purine"

c. "I should not smoke" Raynaud's disease is a disorder of the blood vessels that supply blood to the skin and cause the distal extremities to feel numb and cool in response to cold temperature or stress. during a Raynaud's attack, these arteries narrow, limiting blood circulation to affected areas.

A nurse is providing teaching to a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? a. "I am able to donate blood." b. "I will need to get a booster shot of immune serum globulin every year." c. "I should stop eating raw clams." d. "I can develop this disease by getting a tattoo."

c. "I should stop eating raw clams." Individuals who eat raw or steamed shellfish are at a increased risk of acquiring hepatitis A.

A nurse is providing preoperative teaching for a client who is scheduled for total knee arthroplasty. Which of the following statements by the client indicates an understanding of the teaching? a. "I will wear a continuous movement machine on my knee for 24 hr a day" b. "I should avoid taking NSAID medication for pain after surgery" c. "I should wear elastic stockings on both of my legs" d. "I will begin exercising my legs the day after surgery"

c. "I should wear elastic stockings on both of my legs"

A nurse is providing discharge teaching about foot care to a client who has diabetic neuropathy. Which of the following statements by the client demonstrates an understanding of the teaching? a. "I can use a heating pad on my feet to keep them warm." b. "I can go barefoot as long as I stay inside the house." c. "I will wash my feet daily and apply lotion, except between my toes." d. "I will trim my toenails every morning by rounding the corners."

c. "I will wash my feet daily and apply lotion, except between my toes."

A nurse is teaching a client who has type 2 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching? a. "I will apply moisturizer between my toes." b. "I will soak my feet daily." c. "I'll be sure to wear cotton socks every day." d. "I'll use a heating pad to warm my feet."

c. "I'll be sure to wear cotton socks every day."

A nurse is preparing a client for discharge who is postoperative following a conventional lumbar disk excision. Which of the following statements indicates that the client understands the nurse's instructions? a. "I should have no problem climbing stairs when I get home." b. "I'll wait about 3 weeks before I return to my usual activities." c. "I'll use my heating pad if I feel any muscle spasms in my back." d. "I can go back to driving in about 2 weeks or so."

c. "I'll use my heating pad if I feel any muscle spasms in my back."

A nurse is providing teaching to a client who is receiving chemotherapy and has developed neutropenia. Which of the following statements indicates that the client needs further instructions? a. "I'll keep an antibacterial hand gel in my purse." b. "My partner will have to take care of the cat's litter boxes for a while." c. "I'm planning a large gathering of friends and family for the holidays." d. "I will eat canned fruits and vegetables."

c. "I'm planning a large gathering of friends and family for the holidays." A client who has neutropenia should avoid exposure to infection, so this statement warrants more teaching. A client who has neutropenia should avoid large crowds of people because a large gathering increases the client's risk for exposure to infection

A nurse is providing discharge teaching for a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching? a. "Request a provider's prescription when traveling to alert airport security." b. "Stand at least 3 feet away while using a microwave." c. "Keep your cell phone 6 inches away from your pacemaker when making a call." d. "Avoid showering for the first 2 weeks following surgery."

c. "Keep your cell phone 6 inches away from your pacemaker when making a call."

A nurse is teaching a client who has AIDS about the transmission of PCP. Which of the following pieces of information should the nurse include in the teaching? a. "PCP is sexually transmitted from person to person" b. "you were most likely exposed to a contaminated surface such as a drinking glass" c. "PCP results from an impaired immune system" d. "you might have contracted PCP from a family pet"

c. "PCP results from an impaired immune system" the organism that causes PCP exists as part of the normal flora of the lungs and develops into a fungus. it becomes an aggressive pathogen when the immune system is compromised, causing infection.

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following statements indicates that the client understands the instructions? a. "I should try to drink at least 2 liters of fluid per day." b. "I can still fly out to visit my sister in colorado for a while." c. "Physical activity is good for me, but I need to avoid overexertion." d. "I can still go skiing during the cold winter months."

c. "Physical activity is good for me, but I need to avoid overexertion."

A client who has thrombocytopenia asks the nurse why platelets are so important. Which of the following responses should the nurse make? a. "Platelets help the body fight infection." b. "Platelets help break down clots in the body." c. "Platelets plug breaks in blood vessels." d. "Platelets produce the molecules that carry oxygen."

c. "Platelets plug breaks in blood vessels."

A nurse is providing teaching about nutrients to a client. Which of the following statements should the nurse include? a. "Carbohydrates transport nutrients throughout the body." b. "Fats prevent ketosis." c. "Protein builds and repairs body tissue." d. "Carbohydrates help regulate body temperature."

c. "Protein builds and repairs body tissue."

A nurse is providing teaching to a client who is scheduled for an electroencephalogram in the morning. Which of the following pieces of information should the nurse share? a. "You'll feel some mild electrical sensations like static electricity during the procedure." b. "Do not eat or drink anything expect water after midnight." c. "Shampoo your hair before the procedure and don't use any styling products afterwards." d. "It's common to have temporary short-term memory loss after the procedure."

c. "Shampoo your hair before the procedure and don't use any styling products afterwards." for the electrodes to adhere to the scalp, the client's hair has to be clean and free of oil and hair-care products

A nurse is providing discharge teaching to a client who is post-operative following a right mastectomy for breast cancer. The client will be discharged with 2 Jackson-Pratt drains. Which of the following pieces of information should the nurse include in the teaching? a. "Empty the drainage tubes once per day." b. "Showering is permitted before the drainage tubes are removed." c. "The drainage tubes are removed at the same time as the stitches." d. "Do not begin exercising your arm until the provider removed the drainage tubes."

c. "The drainage tubes often are removed at the same time as the stitches."

A nurse is teaching a client who has leukemia and has developed thrombocytopenia. Which of the following instructions should the nurse include in the teaching? a. "Limit flossing your teeth to once a week." b. "Gently blow your nose if needed." c. "Use and electric razor when shaving." d. "Wear shoes that have a soft sole."

c. "Use and electric razor when shaving." the nurse should instruct the client to use an electric razor to prevent nicks and cuts caused by conventional razors that can increase the risk of bleeding

A client who just learned that he has varian (Prinzmetal's) angina asks the nurse how this type of angina compares with stable angina. Which of the following replies should the nurse make? a. "Exertion often bring on pain." b. "Variant angina occurs randomly at various times." c. "Variant angina can cause changes on your electrocardiogram." d. "Reducing your cholesterol can help you experience less pain."

c. "Variant angina can cause changes on your electrocardiogram."

A nurse is teaching breathing treatment techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? a. "I'll inhale slowly through pursed lips to help me breathe better" b. "When I do my pursed lip breathing, I'll lie down first" c. "When I breathe out through pursed lips, my airways don't collapse between breaths" d. "I'll relax my stomach muscles when I am doing my pursed-lip breathing exercises"

c. "When I breathe out through pursed lips, my airways don't collapse between breaths." breathing through pursed lips slows exhalation and maintains inflation of the distal airways, which enhances respiration for client who has emphysema

A nurse is providing teaching to a client who has type 2 diabetes mellitus. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following responses should the nurse provide? a. "let's discuss this with your doctor; giving up daily pasta may not be necessary." b. "is there another favorite dish you can substitute?" c. "you don't have to give up pasta; just adjust the amount you eat." d. "you can use no-added-salt tomato products on your pasta."

c. "You don't have to give up pasta; just adjust the amount you eat." the American diabetes association recommends individualizing carbohydrate restriction for each client. a careful assessment of the client's usual dietary practices and modifications is an important part of teaching clients to manage this disorder

A nurse is providing teaching to a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make? a. "You will be NPO for 8 hr following the procedure." b. "An allergy to shellfish is a contraindication to this procedure." c. "You will need to be on bed rest following the procedure." d. "A creatinine clearance is needed prior to the procedure."

c. "You will need to be on bed rest following the procedure." a renal biopsy involves a tissue biopsy through needle insertion into the lower lobe of the kidney. the client should maintain bed rest in a supine position with a back roll for support for 2 to 24 hours following the procedure to reduce the risk of bleeding. the nurse can elevate the head of the bed

A nurse is teaching a client who has leukemia and has developed thrombocytopenia. Which of the following instructions should the nurse include in the teaching? a. "limit flossing your teeth to once a week" b. "gently blow your nose if needed" c. "use an electric razor when shaving" d. "wear shoes that have a soft sole"

c. "use an electric razor when shaving the nurse should instruct the client to use an electric razor to prevent nicks and cuts caused by conventional razors that can increase the risk of bleeding

A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information? a. "I'll expect a little leg swelling since I wont be that active for a while." b. "I'll see the doctor every week to change my vena cava filter." c. "I'll call the doctor if I see any blood in my urine or stool." d. "I'll have to take blood thinner for a few more days."

c. 'I'll call the doctor if I see any blood in my urine or stool." Bleeding precautions are essential for clients who had a pulmonary embolism because they take an anticoagulant. They should report any signs of bleeding immediately

A nurse is caring for an adult 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? a. Cholesterol level 195 mg/dL b. Elevated HDL levels c. Elevated LDL levels d. Triglyceride level 135 mg

c. Elevated LDL levels---An elevated LDL level increases a client's risk of atherosclerosis. The client's desirable LDL level is <100 mg/dL.

a nurse is providing teaching to a client who has postmenopausal osteoporosis & a new prescription for intranasal calcitonin-salmon. which of the following statements by the client indicates an understanding of the teaching? a. I will administer a spray into each nostril daily. b. I should expect nasal bleeding for the first week. c. I will need to depress the side arms to activate the pump d. I should expect to take this medication for a short-term course of treatment.

c. I will need to depress the side arms to activate the pump

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? a. metered-dose inhaler b. continuous passive motion machine c. oral-nasal suction equipment d. external defibrillator pads

c. a client who has myasthenia gravis is at risk of aspiration due to progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to autoimmune disease that affects the acetylcholine receptors. the nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress

A nurse in a clinic is assessing a client who was diagnosed with mononucleosis 2 weeks ago. Which of the following findings should the nurse report to the provider immediately? a. headache and fatigue b. swollen lymph nodes in the neck c. abdominal pain in the left upper quadrant d. fever and sore throat

c. abdominal pain in the left upper quadrant when using the urgent vs nonurgent approach to client care, the nurse should determine that the priority findings is the left-upper quadrant pain, which can indicate an enlarged spleen

A nurse is assessing the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder? a. pallor b. jaundice c. absence of hair on the legs d. poor nailbed capillary refill

c. absence of hair on the legs

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should return to the expected reference range within 72 hours of treatment beginning? a. aldolase b. lipase c. amylase d. lactic dehydrogenase

c. amylase pancreatitis is the most common diagnosis for marked elevations in serum amylase. serum amylase begins to increase about 3-6 hours following the onset of acute pancreatitis. the amylase level peaks in 20-30 hours and returns to the expected by pancreatic disorders

A nurse is caring for a client who is postoperative following a total knee arthroplasty and has been prescribed a continuous passive motion machine and PCA. The client tells the nurse, "I am in so much pain.: Which of the following actions should the nurse take first? a. remind the client to push the button for the PCA device b. discuss activities the client may use to distract from the pain c. ask the client to describe the characteristics of the pain d. pause the CPM machine briefly to apply a cold pack to the client's knee

c. ask the client to describe the characteristics of the pain the nurse can use the nursing process to plan client care and prioritize nursing actions. each step of the nursing process builds on the previous step, beginning with an assessment or data collection

A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout. The nurse should identify that which of the following medications can interact with probenecid? a. colchicine b. naproxen c. aspirin d. prednisone

c. aspirin aspirin can decrease the effectiveness of probenecid. the nurse should caution the client to avoid interaction between probenecid and salicylate medications

a nurse is preparing to administer timolol eye drops to a client who has primary open angle glaucoma (POAG). prior to administering the medication, the nurse should recognize that which of the following conditions in the client's medical history is a contraindication to receiving this medication? a. hypertension b. peripheral vision loss c. asthma d. increased intraocular pressure

c. asthma

A nurse is assessing a client who had coronary artery bypass grafts for cardiac tamponade. Which of the following actions should the nurse take? a. check for hypertension b. auscultate for loud, bounding heart sounds c. auscultate blood pressure for pulses paradoxus d. check for a pulse deficit

c. auscultate blood pressure for pulses paradoxus

A nurse is teaching a group of young adult clients about health promotion techniques to reduce the risk of skin cancer. Which of the following instructions should the nurse include? a. apply a broad-spectrum sunscreen 5 min before sun exposure b. wear a sun visor instead of a hat when outside in the sun c. avoid exposure to the midday sun d. use a tanning booth instead of sunbathing outdoors

c. avoid exposure to the midday sun

A nurse is talking with a group of women at a community center about the current recommendations for early detection of breast cancer. The nurse should explain which of the following options? a. begin monthly breast self-examinations at age 40 b. have a clinical breast examination each year after ago 30 c. begin annual mammograms at age 40 d. have breast magnetic resonance imaging every 5 years after age 50

c. begin annual mammograms at age 40

A charge nurse is observing a newly licensed nurse provide care for a client who is receiving internal radiation therapy for the treatment of cervical cancer. For which of the following actions by the newly licensed nurse should the charge nurse intervene? a. leaving soiled linens in a container in the client's room b. instructing visitors to remain 2 m away from the client c. borrowing a dosimeter film badge from another nurse before entering the client's room d. removing an extra IV pole from the client's room to be used for another client

c. borrowing a dosimeter film badge from another nurse before entering the client's room a nurse should never borrow a dosimeter film badge from another staff member. nurses who are caring for the client should each have a personal badge and wear it while in the client's room. the badge measures the radiation exposure that the nurse is receiving, and each film badge will indicate the nurse's cumulative radiation exposure

A nurse is assessing a client who has Addison's disease. Which of the following skin manifestations should the nurse expect to find? a. purple striae on the chest and abdomen b. butterfly rash across the bridge of the nose c. bronze pigmentation of the skin d. jaundice of the face and sclera

c. bronze pigmentation of the skin A client who has Addison's disease will have a darkening of the skin on both exposed and unexposed parts of the body due to a hormone deficiency caused by damage to the outer layer of the adrenal gland

a nurse is teaching a client who has primary adrenal insufficiency (Addison's disease) & a prescription for hydrocortisone. which of the following statements should the nurse include in the teaching about this medication? a. you may need to take a lower dosage when you are ill or experiencing stress b. take this medication before going to bed because it will make you tired c. carry a supply of pills & a single-use injectable preparation with you at all times d. you will need to stop this medication before routine procedures such as a colonoscopy

c. carry a supply of pills & a single use injectable preparation with you at all times

A nurse is performing medication reconciliation for a newly admitted client who has rheumatoid arthritis. Which of the following medications should the nurse identify as the treatment for this condition? a. misoprostol b. dantrolene c. celecoxib d. colchicine

c. celecoxib

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input and that his abdomen is distended. Which of the following actions should the nurse take? a. insert an indwelling urinary catheter b. administer pain medication to the client c. change the client's position d. place the drainage bag above the client's abdomen

c. change the client's position this client is retaining the dialysate solution after the dwell time. the nurse should ensure that the clamp is open and the tubing is not kinked and should reposition the client to facilitate the drainage of the solution from the peritoneal cavity

A nurse is caring for a client who is postoperative following a urinary diversion to treat bladder cancer. Which of the following interventions should the nurse include in the plan of care? a. empty the collection pouch when it is 2/3 full b. expect urine outflow into pouch to begin 1-2 days after surgery c. change the collection pouch in the early morning d. place an aspirin in the collection pouch to control odor

c. change the collection pouch in the early morning the nurse should plan to change the urinary collection pouch in the early morning when urine output is reduced

A nurse responds to a call from an assistive personnel that a client just had a seizure and is unconscious. Which of the following assessments is the nurse's priority? a. measure the client's vital signs b. perform a neurological examination c. check airway patency d. assess the client for injuries

c. check airway patency

A nurse is caring for a client who reports calf pain. What is the first action the nurse should take? a. notify the provider b. elevate the affected extremity c. check the affected extremity for warmth and redness d. prepare to administer unfractionated heparin

c. check the affected extremity for warmth and redness

A nurse is caring for a client who had a nephrostomy tube inserted 8 hours ago. Which of the following actions should the nurse include in the client's plan of care? a. flush the nephrostomy tube every 4 hours with sterile water b. clamp the nephrostomy tube intermittently to establish continence c. check the skin at the nephrostomy site for irritation from urine leakage d. monitor for and report any blood-tinged drainage to the provider immediately

c. check the skin at the nephrostomy site for irritation from urine leakage

A nurse in a dermatology clinic is using the ABCDE method while screening several skin lesions for skin cancer on a client. Which of the following findings should the nurse report to the provider? a. symmetric shape b. border regularity c. color variation within a lesion d. diameter >4mm

c. color variation within a lesion

A nurse is planning discharge teaching for a client who is postoperative following a traditional open cholecystectomy. Which of the following learning needs of the client is the nurse's priority? a. dietary recommendations b. incision care c. coughing and deep-breathing exercises d. pain management

c. coughing and deep-breathing exercises The greatest risk to the client is respiratory compromise. Therefore, learning how to perform coughing and deep-breathing exercises to promote lung expansion and secretion removal is the priority

a nurse is caring for a client who has diabetes insipid. which of the following laboratory values should the nurse identify as reflecting a contraindication to receiving vasopressin to treat this disorder? a. sodium 152 mEq/L b. potassium 6.0 mEq/L c. creatinine clearance 50 ml/min d. aspirate aminotransferase (AST) 52 units/L

c. creatinine clearance 50mL/min

A client is admitted to the emergency department following a motorcycle crash. the nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? a. friction rub b. crackles c. crepitus d, tactile fremitus

c. crepitus crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of pneumothorax

A nurse is caring for a client who has a peripherally inserted central catheter in place. Which of the following actions should the nurse take when handling this central venous access device? (select all that apply) a. use a 5 mL syringe to flush the line b. cleanse the insertion site with half-strength hydrogen peroxide c. flush the line with sterile 0.9% sodium chloride before and after medication administration d. access the PICC for blood sampling e. perform a heparin flush of the line at least daily when not in use

c. d. e.

a nurse is planning care for a young adult client who has a terminal illness. which of the following concepts of death should the nurse consider for this client? a. death is unacceptable under any circumstances b. magical thinking helps avoid thoughts of death c. death as viewed as an interruption of what might have been d. death is a natural consequence of a deteriorating body

c. death is viewed as an interruption of what might have been

A nurse is planning care for a client who has cholelithiasis. Which of the following interventions should nurse include in the plan? a. restrict the client's fluid intake b. restrict the client's calcium intake c. decrease the client's fat intake d. decrease the client's potassium intake

c. decrease the client's fat intake the nurse should decrease the client's fat intake to reduce the occurrence of biliary colic

A nurse is caring for a child who had her spleen removed following a bicycle accident. The child's parent asks the nurse about the role of the spleen in the body. The nurse should explain that the spleen performs which of the following functions? a. maintains fluid balance b. regulates calcium in the blood c. destroys old blood cells d. produces prothrombin

c. destroys old blood cells the nurse should tell the parent that the spleen destroys old blood cells, filters antigens, and stores platelets. a client without a spleen has an increased risk of infection and sepsis due to a reduces immune function

A nurse is preparing a client who has a brain tumor for computed tomography. Which of the following factors affects the manner in which the nurse will prepare the client for the scan? a. no food or fluids consumed for 4 hr b. difficulty recalling recent events c. development of hives when eating shrimp d. paresthesias in both hands

c. development of hives when eating shrimp an allergy to shellfish is a contraindication for the use of contrast media during a CT scan. the nurse should inform the provider and explain to the client that this factor might alter how the technician performs the CT scan.

A nurse is assessing a client who has Grave's disease. Which of the following findings should the nurse expect the client to display? a. constipation b. cold intolerance c. difficulty sleeping d. anorexia

c. difficulty sleeping A client who has Graves' disease can have difficulty sleeping and anxiety due to the overproduction of thyroid hormone

A nurse is assessing a female client who reports severe joint pain. The nurse should identify that which of the following factors places the client at risk for gout? a. perimenopause b. migraine headaches c. diuretic use d. irritable bowel syndrome

c. diuretic use

A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? a. pitting edema b. areas of reddish-brown pigmentation c. dry, pale skin with minimal body hair d. sunburned appearance with desquamation

c. dry, pale skin with minimal body hair

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? a. bradycardia with ST-segment depression b. relief of chest pain with deep inspiration c dyspnea with hiccups d. chest pain that increases when sitting upright

c. dyspnea with hiccups a client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. these manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade

A nurse is caring for a client during the first 72 hr following a cerebrovascular accident. Which of the following actions should the nurse take? a. turn the client's head to the side with the head of the bed elevated 60-degrees b. place the head of the bed flat with pillows under the client's neck and feet c. elevate the head of the bed 25-30-degrees with the client in a neutral midline position d. position the client ina dorsal recumbent position with pillows under the head and knees

c. elevate the head of the bed 25-30-degrees with the client in a neutral midlines position

A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect? a. hypokalemia b. hypernatremia c. elevated Hct d. Decreased Hgb

c. elevated Hct the nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit as blood volume is reduced by vascular dehydration

a nurse is reviewing the medical record of a client who is postmenopausal & has osteoporosis. the client has a new prescription for alendronate sodium. which of the following findings in the client's history should the nurse recognize is a contraindication to this medication? a. glaucoma b. Paget's disease c. esophageal achalasia d. long-term corticosteroid use

c. esophageal achalasia

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? a. instruct the client to cough b. administer oxygen via face mask c. evaluate the client for stridor d. keep the client in a semi to high-fowler's position

c. evaluate the client for stridor

A nurse is screening a client for skin cancer. When teaching the client about skin cancer risk, which of the following risk factors should the nurse include? a. cigarette smoking b. low-fiber diet c. excessive exposure to ultraviolet light d. human papillomavirus

c. excessive exposure to ultraviolet light

A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend? a. foods high in vitamin C b. foods low in fat c. foods high in fiber d. foods low in calories

c. foods high in fiber long-term low-fiber eating habits and increased intraocular pressure lead to straining during bowel movements, causing the development of diverticula. high-fiber foods help strengthen and maintain the active motility of the gastrointestinal tract

A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates that the client is developing dialysis disequilibrium syndrome? a. elevated BUN b. bradycardia c. headache d. temperature of 102.5

c. headache DSS is a CNS disorder that can develop in clients who are new to dialysis due to the rapid removal of solute and changes in the blood pH

A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following pieces of information should the nurse include in the teaching? a. hospitalization is required when administering each treatment b. the maximum effect of the medication will occur in 6 months c. hypertension is a common adverse effect of this medication d. blood transfusions are needed with each treatment

c. hypertension is a common adverse effect of this medicaiton

a nurse is caring for a client who is taking fludrocortisone. which of the following findings indicates to the nurse that the client is experiencing an adverse effect of the medication? a. hypotension b. weight loss c. hypokalemia d. anorexia

c. hypokalemia

A nurse is reviewing the dietary choices of a client who has chronic pancreatitis. Which of the following food items should the nurse suggest removing from the client's menu for the following day? a. white rice b. broiled cod c. ice cream d. canned peaches

c. ice cream clients who have chronic pancreatitis should limit their fat intake to no more than 30% to 40% of total calories. ice cream is high in fat, with 48 g of fat in 1 cup serving vanilla ice cream

A nurse is assessing a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment? a. inability to remember current age b. inability to count backwards c. inability to locate eyeglasses d. inability to recall names of family members

c. inability to locate eyeglasses

A nurse is teaching a client who has hyperthyroidism about managing this disorder. Which of the following recommendations should the nurse include? a. reduce total hours of sleep b. keep the immediate environment warm c. increase caloric intake with meals d. gradually increase activity

c. increase caloric intake with meals clients whose thyroid hormone levels are high have increased protein, lipid, and carbohydrate metabolism, resulting in the loss of protein stores and a negative nitrogen balance

A nurse is caring for a client who has a 20 year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? a. place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min b. prepare the client for possible endotracheal intubation and mechanical ventilation c. increase the oxygen flow and request an arterial blood gas determination d. position the client supine and administer an antianxiety medication

c. increase the oxygen flow and request an arterial blood gas determination the client requires oxygen therapy at a rate that will keep the oxygen saturation between 88% and 92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements

A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? a. place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min b. prepare the client for possible endotracheal intubation and mechanical ventilation c. increase the oxygen flow and request an arterial blood gas determination d. position the client supine and administer an antianxiety medicatoin

c. increase the oxygen flow and request an arterial blood gas determination the client requires oxygen therapy at a rate that will keep the oxygen saturation between 88% and 92%. the nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements

A nurse is caring for a client who has abdominal pain and possible pancreatitis. Which of the following laboratory results should the nurse identify as an indication of pancreatitis? a. decreased white blood cell count b. increased albumin level c. increased serum lipase level d. decreased blood glucose level

c. increased serum lipase level Due to the release of lipase into the pancreas and autodigestion, pancreatitis causes and increase serum lipase level

A nurse is assessing a client who has increased intracranial pressure and has received intravenous mannitol. Which of the following findings indicates a therapeutic effect of this medication? a. decreased blood glucose b. decreased bronchospasms c. increased urine output d. increased temperature

c. increased urine output mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing intracranial fluid an inhibiting the reabsorption of water and electrolytes in the kidneys. Increased urine output and decreased intracranial pressure are therapeutic effects of this medication

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan? a. administer ferrous sulfate supplementation b. increase dietary intake of folic acid c. initiate weekly injections of vitamin B12 d. initiate a blood transfusion

c. initiate weekly injections of vitamin B12

A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching? a. dry the ear canal within a cotton swab after a swimming b. apply an ice pack to the ear to relieve pain c. instill a diluted alcohol solution into the ear after swiming d. irrigate the ear with cool tap water to clean

c. instill a diluted alcohol solution into the ear after swimming

A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? a. cover the insertion site with a hydrocolloid dressing after removal b. provide pain medication immediately after removal c. instruct the client to perform Valsalva maneuver during removal d. delegate removal of the chest tube to a LPN

c. instruct the client to perform the valsalva maneuver during removal the nurse should instruct the client to perform the valsalva maneuver during the removal to maintain the appropriate amount of negative pressure in the chest in order to prevent air entry into the pleural space

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and has continuous bladder irrigation. The nurse notes no drainage in the client's urinary drainage bag over 1 hour. Which of the following actions should the nurse take? a. a. instruct the client to attempt to void around the indwelling urinary catheter b. increase the rate of irrigation fluid instillation c. irrigate the indwelling urinary catheter with a syringe d. prepare to administer a diuretic

c. irrigate the indwelling urinary catheter with a syringe no drainage in the urinary drainage bag indicates an obstruction. the nurse should gently irrigate the indwelling urinary catheter as prescribed to clear the obstruction and allow urine and irrigating fluid to drain

A nurse is assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect? a. tonic-clonic seizures b. report of a severe headache c. weakness of the lower extremities d. decreased level of consciousness

c. weakness of the lower extremities

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect? a. urine negative for ketones b. distended neck veins c. Kussmaul respirations d. elevated blood pressure

c. kussmaul respirations the nurse should expect this client with DKA to experience Kussmaul respirations. these deep and rapid respirations are the body's attempt to exhale carbon dioxide to reverse the metabolic acidosis that occurs with DKA

A nurse is assessing a client who was admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment the nurse should perform to determine a change in the client's neurological status? a. vital signs b. body posture c. level of consciousness d. examination of pupils

c. level of consciousness

A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? a. endoscopic sclerotherapy b. liver lobectomy c. liver transplant d. transjugular intrahepatic portal systemic shunt placement

c. liver transplant fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. consequently, liver transplantation has become the treatment of choice for these clients

A nurse is caring for a client who is postoperative following a lumbar disk excision. Which of the following interventions should the nurse include in the client's plan of care? a. keep the client's legs flat with the knees extended b. encourage the client to sit up in a chair for as long as possible c. logroll the client in bed for care procedures d. expect urinary retention for the first postoperative day

c. logroll the client in bed for care procedures

a nurse is reviewing the medication administration record of a client who is receiving an opioid medication for pain. which of the following prescriptions should the nurse clarify with the provider? a. metoprolol b. ondansetron c. lorazepam d. naloxone

c. lorazepam

A nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions in the top priority? a. monitor intake and output b. administer antibiotics c. monitor respiratory status d. encourage fluid and food intake

c. monitor respiratory status

A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? a. pericardial friction rub b. weight gain c. night sweats d. cyanosis of the fingertips

c. night sweats night sweats and fever are clinical manifestations of tuberculosis

a nurse is teaching the parent of a child who has severe reactive airway disease about glucocorticoid therapy. the parent asks why her child has to inhale the medication instead of taking it orally. which of the following pieces of information should the nurse provide to the parent? a. inhaled glucocorticoids are less likely to cause thrush b. oral glucocorticoids are hazardous during times in stress c. oral glucocorticoids are more likely to slow linear growth in children d. inhaled glucocorticoids are more effective for acute bronchospasm

c. oral glucocorticoids are more likely to slow linear growth in children

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? a. metered-dose inhaler b. continuous passive motion machine c. oral-nasal suction equipment d. external defibrillator

c. oral-nasal suction equipment

A nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of the following adverse effects should the nurse anticipate from chemotherapy? a. gingival hyperplasia b. hirsutism c. pancytopenia d. weight gain

c. pancytopenia Pancytopenia (a deficiency of WBCs, RBCs, and platelet count) is an expected adverse effect of chemotherapy

A nurse is caring for a client who has a depressed skull fracture of the bone that makes up the larger part of the upper and side wall of the cranium. This fracture is located on which of the following bones? a. sphenoid b. occipital c. parietal d. frontal

c. parietal

a hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. people who practice the islamic faith pray over the deceased for a period of 5 days before burial b. people who practice the hindu faith bury the deceased with their head facing north c. people who practice judaism stay with the body of the deceased until burial d. people who are practicing the buddhist faith have the female family members prepare the body following death

c. people who practice judaism stay with the body of the deceased until burial

A nurse is planning care for a client following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan? a. position the client with her legs adducted b. internally rotate the client's affected hip c. place a pillow between the client's legs d. instruct the client to avoid flexing her hip more than 95-degrees

c. place a pillow between the client's legs

A nurse is teaching a newly licensed nurse about collecting a 24-hr urine specimen for creatinine clearance. Which of the following instructions should the nurse include? a. include the first voided specimen at the start of the collection period b. discard the last voided specimen at the end of the collection period c. place signs in the bathroom as a reminder about the test in progress d. instruct the client to increase exercise during the 24-hr period

c. place signs in the bathroom as a reminder about the test in progress the nurse should place signs in the bathroom and alert family members of the test in progress so that everyone save the specimens appropriately throughout the test

A nurse is preparing a community education program about reducing the risk of osteoporosis. Which of the following pieces of information should the nurse include? a. avoid sun exposure b. take a calcium supplement once each day if at risk for osteoporosis c. walking is the preferred mode of exercise to maintain strong bones d. caffeine intake minimizes the risk of developing osteoperosis

c. walking is the preferred mode of exercise to maintain strong bones the nurse should emphasize that regular walks are the preferred weight-bearing exercise to build and maintain strong bones

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following findings indicates that the AAA is expanding? a. increased BP and decreased pulse rate b. jugular vein distention and peripheral edema c. report of sudden, severe back pain d. report of retrosternal chest pain radiating to the left arm

c. report of sudden, severe back pain an aortic aneurysm is a weak spot in the wall of the aorta that allows the aorta to expand and increase in diameter. sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots

A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? a. respiratory acidosis b. metabolic acidosis c. respiratory alkalosis d. metabolic alkalosis

c. respiratory alkalosis because of rapid breathing, the client is exhaling excessive amounts of carbon dioxide. This loss of carbon dioxide decreases the hydrogen ion level of the blood, which causes the pH to increase and results in respiratory alkalosis

a home health nurse is visiting an older adult client with severe dementia the clients son, who serves as her primary caregiver, reports being exhausted from working part time & caring for his mother at home. which of the following options should the nurse suggest to the caregiver? a. rehab b. assisted living facility c. respite care d. adult day care facility

c. respite care

A nurse is assessing a client who reports an acute visual disturbance that he describes as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that the client might have which of the following disorders? a. cataracts b. angle-closure glaucoma c. retinal detachment d. macular degeneration

c. retinal detachment

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following indicates that a possible bowel perforation has occurred? a. elevated blood pressure b. bowel sounds increased in frequency and pitch c. rigid abdomen d. emesis of undigested food

c. rigid abdomen

A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure. This increase in ICP is due to which of the following? a. decreased cerebral perfusion b. leakage of cerebral spinal fluid c. rigid skull containing cranial contents d. brain herniated into the brainstem

c. rigid skull containing cranial contents the nurse should identify that the client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP

a nurse is teaching self-administration of NPH insulin to a client who has type 2 diabetes mellitus. which of the following instructions should the nurse include? a. alternate injecting doses between the abdomen & thigh b. shake the vial before withdrawing the dosage c. roate injection sites within the same area d. discard the vial if the insulin is cloudy

c. rotate injection sites within the same area

A nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions? a. trendelenburg b. prone c. semi-fowler's d. sims'

c. semi-fowler's to prevent an intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30 degrees. this positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? a. multiple floaters b. flashes of light in front of the eye c. severe eye pain d. double vision

c. severe eye pain severe eye pain is a manifestation of acute angle-closure glaucoma

a nurse is providing teaching to an older adult client who has constipation. which of the following statements should the nurse include in the teaching? a. drink a minimum of 1000 mL of fluid daily b. increase your intake of refined-fiber foods c. sit on the toilet 30 min after eating a meal d. take a laxative every day to maintain regularity

c. sit on the toilet 30 min after eating a meal

A nurse is caring for a client who has human immunodeficiency virus. Which of the following types of isolation should the nurse implement to prevent the transmission of HIV? a. protective isolation b. droplet precautions c. standard precautions d. airborne precautions

c. standard precautions

A nurse is caring for a client who has cholelithiasis and will undergo a cholecystectomy. The client states she does not understand how she will be alright without her gallbladder. The nurse should explain to the client that which of the following is the main function of the gallbladder? a. producing bile b. adding digestive enzymes to bile c. storing bile d. eliminating bile

c. storing bile the primary function of the gallbladder is to store bile. because this organ is only for storage, the client's liver will still produce the bile needed for digestion. small amounts of bile will continuously enter the duodenum, where it will perform various functions

A nurse is assessing a client who is receiving a transfusion of packed red blood cells. Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? a. severe hypertension b. low body temperature c. sudden oliguria d. decreased respirations

c. sudden oliguria the nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. this type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. this reaction results from the client's antibodies reacting to the transfused RBCs

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? a. wheezing b. bradypnea c. tachycardia d. diaphoresis

c. tachycardia

a nurse is preparing to irrigate a client's wound. which of the following actions should the nurse take? a. use a 10mL syringe b. attach a 22-gauge catheter to the syringe c. warm the irrigating solution to 37 C (98.6 F) d. administer an analgesic 10 mins before the irrigation

c. warm the irrigating solution to 37 C (98.6 F)

A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? a. clamp the chest tube if there is continuous bubbling in the water seal chamber b. keep the chest tube drainage system at the level of the right atrium c. tape all connections between the chest tube and drainage system d. empty the collection chamber and record the amount of drainage every 8 hr

c. tape all connections between the chest tube and drainage system the nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting

A nurse is assessing the abdominal incision of a client who is 3 days postoperative. The incision is slightly edematous and pink with crusting on the edges and is draining serosanguineous fluid. Which of the following assessments describes the incision? a. the incisions is showing early signs of infection b. the incision is showing early signs of dehiscence c. the incision is should signs of healing without complications d. the incision is should signs of developing a fistula

c. the incision is should signs of healing without complications these assessment findings are consistent with appropriate healing without complications

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? a. first-degree frostbite b. second-degree frostbite c. third-degree frostbite d. fourth-degree frostbite

c. third-degree frostbite when a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled, and the skin does not blanch

A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is schedules for a standard electroencephalogram. Which of the following instructions should the nurse include in the teaching? a. remain NPO 6-8 hr prior to the EEG b. take a sedative the night prior of the EEG c. thoroughly shampoo her hair prior to the EEG d. sleep for at least 8 hr during the night prior to the test

c. thoroughly shampoo her hair prior to the EEG

a nurse is caring for a client who has heart failure & is taking oral furosemide 40mg daily. for which of the following adverse effects should the client be taught to monitor & notify the provider if it occurs? a. nasal congestion b. tremors c. tinnitus d. frontal headache

c. tinnitus

A nurse is providing teaching to a client who has Addison's disease about healthy snack foods. Which of the following food choices by the client indicates an understanding of the teaching? a. slices bananas b. baked potato c. turkey and cheese sandwhich d. plain yogurt with peaches

c. turkey and cheese sandwich

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? a. confluent, honey-colored, crusted lesions b. a large, tender nodule, nodular skin lesions d. a fluid-filled vesicular rash in the genital region

c. unilateral, localized, nodular skin lesion

A nurse is caring for a client who has just returned from the surgical suite following a right nephrectomy. Which of the following indicates that the client is meeting a successful short-term goal following this procedure? a. the client requests pain medication upon arrival from surgery b. a chest x-ray shows consolidation in the right lower lobe c. urinary output is 35-50 mL/hr consistently d. the client has slight distention

c. urinary output is 35-50 mL/hr consistently following a nephrectomy, the client should have a urine output of at least 30 mL/hr consistently. a lower output indicates inadequate blood flow to the remaining kidney

A nurse is caring for a client with Clostridium difficile who has contact-isolation precautions in place. Which of the following actions should the nurse perform? a. instruct visitors to maintain a distance of at least 3 ft from the client b. wash hands with antimicrobial soap after leaving the client's room c. use dedicated equipment for the client d. keep the doors to the client's room closed at all times

c. use dedicated equipment for the client The nurse should use dedicated equipment that is left in the room for a client who has contact-isolation precautions in place

A nurse is obtaining a client's health history who has cancer of the cervix. Which of the following manifestations should the nurse expect? a. weight gain b. oliguria c. vaginal bleeding d. back pain

c. vaginal bleeding the most common manifestations of cancer of the cervix is painless vaginal bleeding

A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24hr? a. infective endocarditis b. pericarditis c. ventricular dysrhythmias d. pulmonary emboli

c. ventricular dysrhythmias After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system

A nurse is caring for client who has continuous bladder irrigation following a transurethral resection of the prostate. Which of the following findings should the nurse report the to provider? a. output equal to the instilled irrigant b. client report of bladder spasms c. viscous urinary output with clots d. client report of a strong urge to urinate

c. viscous urinary output with clots the nurse should report urine output that is bright red with clots or urine that resembles ketchup to the provider because this is an indication of arterial bleeding

A nurse is caring for a client who has a new diagnosis for pernicious anemia. The nurse should expect the client's provider to prescribe which of the following medications for this client? a. ferrous sulfate b. epoetin alfa d. vitamin B12 d. folic acid

c. vitamin B12 the nurse should expect the client's provider to prescribe vitamin B12 for pernicious anemia

A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that which of the following nutrients promotes wound healing? a. vitamin B1 b. calcium c. vitamin C d. potassium

c. vitamin C a diet high in protein and vitamin C is recommended because these nutrients promote wound healing

A nurse is providing nutrition education to a client who has osteomalacia. The nurse should identify that this condition is caused by a deficiency in which of the following nutrients? a. fluoride b. vitamin A c. vitamin D d. phosphorus

c. vitamin D

A nurse is caring for a client who is scheduled to repair an open hip fracture. In which of the following positions should the nurse plan to place the client postoperatively? a. with the leg on the affected side adducted b. with the hip externally rotated on the affected side c. with the leg on the affected side abducted d. with the hip flexed to 90 degrees on the affected side

c. with the lef on the affected side abducted

A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first? a. hang an IV infusion of 0.9% sodium chloride with the blood b. compare the client's identification number with the number on the blood c. witness the informed consent document d. obtain pretransfusion vital signs

c. witness the informed consent document

a nurse is providing teaching to a client who has tuberculosis (TB) & a prescription for isoniazid. which of the following instructions should the nurse include? a. you will need to take this medication for the rest of your life to prevent recurrence b. your provider will monitor your thyroid function while you are taking this medication c. you should take this medication on an empty stomach d. you should take this medication with an antacid

c. you should take this medication on an empty stomach

A nurse is providing teaching to a client who is preoperative prior to a transurethral resection of the prostate. Which of the following client statements indicates and understanding of the informaiton? a. "I will not need to have a urinary catheter following this procedure." b. "I will expect my urine to be cloudy after having this procedure." c. "At least I won't have leakage of urine after having this procedure." d. "I will feel the urge to urinate following this procedure."

d "I will feel the urge to urinate following this procedure."

A client who has stage II breast cancer asks the nurse about sites of metastasis for this cancer. Which of the following responses should the nurse provide? a. "It's too soon to worry about something that might not happen." b. "Breast cancer tends to metastasize to the stomach." c. "Metastasis is unlikely since we detected your cancer early." d. "Breast cancer tends to metastasize to the bones."

d. "Breast cancer tends to metastasize to the bones."

A nurse is providing teaching about food choices to a client who has diabetes mellitus. Which of the following statements by the client indicates and understanding of the teaching? a. "I will need to eliminate sweet desserts from my diet." b. " I should avoid using sucralose in my coffee." c. "I should consume alcohol between meals in moderation." d. "I should replace white bread with whole-grain bread."

d. "I should replace white bread with whole-grain bread." clients with diabetes have the same fiber requirements as the general population. fiber content can be increased by substituting white bread, which is made with refined grains, with whole-grain bread, which retains the outer layer of the grain that is higher in fiber.

A nurse is providing teaching to a client who has cancer and is undergoing external radiation treatment. Which of the following statements by the client indicates an understanding of the teaching? a. "I should use petroleum-based lotions on the areas being radiated" b. "I will dry the areas being radiated by rubbing in a circular pattern" c. "I will apply sunscreen to the areas being radiated when I spend time in the sun" d. "I should use my hand, instead of a washcloth, to wash the areas being radiated"

d. "I should use my hand, instead of a washcloth, to wash the areas being radiated" washing the areas being radiated with the hand is gentler than using a washcloth

A nurse is providing teaching to a client who has cancer and is undergoing external radiation treatment. Which of the following statements by the client indicates an understanding of the teaching? a. "I should use petroleum-based lotions on the areas being radiated." b. "I will dry the areas being radiated by the rubbing in a circular pattern." c. "I will apply sunscreen to the areas being radiated when I spend time in the sun." d. "I should use my hand, instead of a washcloth, to was the areas being radiated."

d. "I should use my hand, instead of a washcloth, to wash the areas being radiated." washing the areas being radiated with the hand is gentler than using a washcloth

A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that the client understands the impact of the surgery? a. "I'm not going to be able to cough for a while after the surgery." b. "after I recover from the anesthesia, I'll be able to eat regular food again." c. "after the surgery, my voice will gradually return but might be weak." d. "I understand that I will have a permanent tracheostomy after the surgery."

d. "I understand that I will have a permanent tracheostomy after the srugery."

A hospice nurse is providing education about palliative care to the partner of a client who has end-stage liver cancer. Which of the following statements by the partner indicates an understanding of teaching? a. "I will do my best to try to get him to eat something" b. "I will lay him flat if his breathing becomes shallow" c. "I will use an electric blanket to keep him warm." d. "I will continue to talk to him, even when he's sleeping"

d. "I will continue to talk to him, even when he's sleeping" the nurse should reinforce to the partner that the client's hearing is thought to be the last sense to leave during the dying process. therefore, continue to communicate softly with the client

A nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure? a. "I'll drink less water so I don't have to catheterize myself too often." b. "I must use sterile technique for each of the catheterizations." c. "I should stop the catheterization when I have removed 150 mL of urine." d. "I will perform intermittent self-catheterization every 2-3 hr."

d. "I will perform intermittent self catheterization every 2-3 hr."

A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid coughing will hurt after the surgery." Which of the following statements by the nurse is appropriate? a. "After the surgeon removes the lung, you will not need to cough." b. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." c. "Don't worry. You will have a pump that delivers pain medication as needed, so you will have very little pain." d. "I will show you how to splint your incision while coughing."

d. "I will show you how to splint your incision while coughing."

A nurse is teaching a client who has a new prescription for alendronate for the treatment of osteoporosis. Which of the following statements by the client indicates an understanding of the teaching? a. "I will take the medication in the evening." b. "I will drink a full glass of milk with the medication." c. "I will take the medication at mealtime." d. "I will sit up upright after taking the medication."

d. "I will sit upright after taking the medication." A client taking alendronate should sit upright for 20 minutes after administration to prevent esophageal irritation and ulceration. Therefore, the nurse should identify this statement as indicating an understanding of the teaching

A nurse is planning discharge teaching for a client who has systemic lupus erythematosus. Which of the following instructions should the nurse include? a. "Avoid the use of NSAIDs." b. "Stop taking the corticosteroids when your symptoms resolve." c. "Exposure to ultraviolet light will help control the skin rashes." d. "Monitor your body temperature and report any elevations promptly."

d. "Monitor your body temperature and report any elevations promptly." SLE is a chronic autoimmune disorder that can affect any organ of the body. With SLE, the body's immune system becomes hyperactive, forming antibodies that attack tissues and organs, including the skin, joints, kidneys, brain, heart, lungs, and blood. SLE is characterized by periods of exacerbation and remissions. The nurse should teach the client to monitor body temperature and report any elevations promptly, as a fever can suggest either an exacerbation or a potentially life-threatening infection

A nurse is teaching a 70-year old client about risk factors for heart failure. The client has mild asthma, diabetes mellitus, and coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? a. "My diabetes will not increase my risk of heart failure." b. "My asthma make it more likely for me to have heart failure." c. "My age does not increase my risk of heart failure." d. "My coronary artery disease is a risk factor for heart failure."

d. "My coronary artery disease is a risk factor for heart failure."

A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? a. "Move between the bed and the wheelchair once every 2 hr." b. "Make sure that your caregiver massages your skin daily." c. "Use a rubber ring when sitting on the bedside." d. "Shift your weight in the wheelchair every 15 min."

d. "Shift your weight in the wheelchair every 15." This response addresses the safety issue ulcer risk. Pressure ulcers are most likely to develop if the client does not shift position frequently to relieve pressure

A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following pieces of information should the nurse include in the teaching? a. "Wear nylon socks with shoes." b. "Wear flip flops instead of going barefoot when outside." c. "Apply moisturizing cream between your toes." d. "Wash your feet daily using lukewarm water and soap."

d. "Wash your feet daily using lukewarm water and soap." A client who has diabetes mellitus should wash the feet daily with lukewarm water and soap. The client should keep the feet clean and free from diet, which can cause infection, and inspect the feet daily for cuts or calluses, which can develop into a foot ulcer

A nurse is teaching a client about the prostate-specific antigen test. Which of the following directions should the nurse provide? a. "You should fast for 8 hours after the PSA test." b. "Annual PSA screening should begin at age 40." c. "Expected PSA values will decrease as you get older." d. "You should not ejaculate for 24 hours prior to the PSA test."

d. "You should not ejaculate for 24 hours prior to the PSA test."

A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? a. "apply warm compresses to the face" b. "take aspirin 650 mg by mouth for mild pain" c. "close your mouth when sneezing" d. "lie on your back with your head elevated 30 degrees when resting"

d. "lie on your back with your head elevated 30 degrees when resting" the nurse should instruct the client to rest in the semi-fowlers position to prevent aspiration of nasal secretions

A nurse is discussing the difference between rheumatoid arthritis and osteoarthritis with a newly licensed nurse. which of the following pieces of information should the nurse include about osteoarthritis? a. "osteoarthritis is caused by autoimmune processes." b. "osteoarthritis leads to a decreased erythrocyte sedimentation rate." c. "osteoarthritis affects other organ systems." d. "osteoarthritis can impair a joint on a single side of the body."

d. "osteoarthritis can impair a joint on a single side of the body." the nurse should identify unilateral joint involvement as a findings of osteoarthritis. a client who has RA experiences symmetrical joint impairment

A nurse is caring for a client who has colitis and reported increased exacerbations due to stress at work. Which of the following responses should the nurse make? a. "I will contact the social worker so you can discuss career alternatives." b. "have you thought about discussing the possibility of a part-time assignment with your employer?" c. "why don't you ask your employer to relieve you of some work until you are stronger?" d. "perhaps we should review your coping mechanisms and talk about other alternatives."

d. "perhaps we should review your coping mechanisms and talk about other alternatives." reviewing coping mechanisms and alternative coping patterns will promote coping skills that can assist the clients in reducing stress.

A nurse is collecting a health history from a female client who is undergoing screening for breast cancer. Which of the following factors increases the client's risk of developing breast cancer? a. obesity b. oral contraceptive use c. alcohol use d. age over 50 years

d. age over 50 years a female who is over 50 years of age has an increased risk of developing breast cancer

A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should the nurse include? a. "you will need to apply a cold pack to the site 3 times a day" b. "your provider might ask you to walk frequently to increase circulation to the area" c. "you will need to limit your consumption of high-protein foods" d. "your provider might prescribe a central catheter line for long-term antibiotic therapy"

d. "your provider might prescribe a central catheter line for long-term antibiotic therapy" osteomyelitis is an acute or chronic infection. the client will require weeks to months of IV antibiotic therapy for treatment. therefore, the nurse should discuss the need for long-term IV access for antibiotic therapy

A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should the nurse include? a. "you will need to apply a cold pack to the site 3 times a day." b. "your provider might ask you to walk frequently to increase circulation to the area." c. "you will need to limit your consumption of high-protein foods." d. "your provider might prescribe a central catheter line for long-term antibiotic therapy."

d. "your provider might prescribe a central catheter line for long-term antibiotic therapy." osteomyelitis is an acute or chronic bone infection. the client will requires weeks to months of IV antibiotic therapy for treatment. therefore, the nurse should discuss the need for long-term for antibiotic therapy

A nurse is planning to administer fluids to a client who has 25% total body surface area burns. The client has no prior medical history. Which of the following intravenous fluids is contraindicated for this client? a. whole blood b. lactated ringer's c. dextran 40 in 0.9% sodium chloride d. 0.45% sodium chloride

d. 0.45% sodium chloride The nurse should identify that 0.45% sodium chloride is a hypotonic solution and is contraindicated for clients who have burns. Hypotonic fluid has an osmolarity value of <270 mOsm/L, which is less than the expected reference range of osmolarity value for plasma and body fluid of 285 to 295 mOsm/L. Administering a hypotonic solution to this client can cause third-spacing of fluid.

A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? a. 0.45% sodium chloride b. dextrose 5% in 0.9% sodium chloride c. dextrose 10% in water d. 0.9% sodium chloride

d. 0.9% sodium chloride

a nurse is teaching a client who is using patient-controlled analgesia (PCA) pump to deliver morphine for pain management. which of the following statements should the nurse identify as an indication that the client understands the instructions? a. ill limit pushing the button so I don't get an overdose b. if I push the button & still have pain after 2 minute, ill push it again c. ill ask my niece to push the button while im sleeping d. I can still use my transcutaneous electrical nerve stimulation unit while im pushing the PCA button

d. I can still use my transcutaneous electrical nerve stimulation unit while im pushing the PCA button

a nurse is providing teaching to a client who has a urinary tract infection & new prescriptions for phenazopyridine & ciprofloxacin. which of the following statements by the client indicates a need for further teaching? a. if phenazopyridine upsets my stomach, I can take it with meals b. phenazopyridine will relieve my discomfort but ciprofloxacin will get rid of the infection c. I need to drink 2L of fluid per day while I am taking the ciprofloxacin d. I should notify my provider immediately if my urine turns an orange color

d. I should notify my provider immediately if my urine turns an orange color

A nurse is caring for a client who underwent radioallergosorbent (RAST) testing due to seasonal allergies. The nurse should anticipate an elevation in which of the following immunoglobulin laboratory values? a. IgM b. IgA c. IgG d. IgE

d. IgE RAST testing involves measuring the quantity of IgE present in serum after exposure to specific antigens selected on a basis of the client's symptom history. an elevated IgE indicates a positive response and is common among clients who have a history of allergic manifestations, anaphylaxis, and asthma

A nurse is assessing a 66-year old client during a routine physical examination. This is the client's first clinic visit, and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replied "I am not sure, but it's been at least 5 years since I've had any immunizations." Which of the following responses should the nurse provide? a. "In case you had the immunization before, we can't give you another one." b. "You'll need a series of 3 injections." c. "This immunization is unsafe for people over the age of 65 years old." d. "Let's go ahead and give you this immunization."

d. Let's go ahead and give you this immunization." If the client did receive this immunization more than 5 years ago, the nurse should administer another because the client is over 65

A nurse is providing teaching to a class about transient ischemic attacks. Which of the following pieces of information should the nurse include in the teaching? a. A TIA can cause irreversible hemiparesis b. A TIA can be the result of cerebral bleeding c. A TIA can cause cerebral edema d. A TIA can precede an ischemic stroke

d. a TIA can precede an ischemic stroke TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. manifestations of TIA include the loss of vision in an eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness and weakness

A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction? a. sudden hemoptysis b. acute diarrhea c. frontal headache d. acute confusion

d. acute confusion acute confusion is a manifestation of myocardial infarction in clients age 65 or older. other manifestations can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue

A nurse is caring for a client who is recovering at home after inpatient treatment for burn injuries. To increase the protein density of the client's meals, which of the following recommendations should the nurse make to the client's caregiver? a. use sour cream instead of plain yogurt b. add honey to cooked cereals c. use salad dressing in place of mayonnaise d. add chopped hard-boiled eggs to soups and casseroles

d. add chopped hard-boiled eggs to soups and casseroles

A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? a. high-calorie diet b. prior gastrointestinal illnesses c. tobacco use d. alcohol use

d. alcohol use alcohol consumption is a major cause of chronic pancreatitis in the US. long term alcohol use disorder produces hypersecretion of protein in pancreatic secretion, which results in protein plugs and calculi within the pancreatic ducts. alcohol also has a direct toxic effect on the cells of the pancreas. damage to these cells is more likely to occur and to be more severe in client whose diets are poor in protein content and either very high or very low in fat.

A nurse is admitting a client who is in sickle cell crisis. Besides pain management, which of the following interventions should the nurse include in the client's plan of care? a. flexion of the extremities b. therapeutic hypothermia c. upright positioning d. ample hydration

d. ample hydration

A nurse is teaching a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching? a. use an alcohol-based soap to clean lesions b. wear a condom during sexual activity when lesions are present c. take a sitz bath once per day d. apply a warm compress to the lesions

d. apply a warm compress to the lesions this is to relieve discomfort

A nurse in the emergency department is preparing to discharge a client following a Grade II (moderate) ankle sprain. Which of the following instructions should the nurse plan to give to the client? a. perform passive range-of-motion exercises of the ankle hourly b. keep the affected extremity in a dependent position c. wrap a loose dressing around the affected ankle d. apply cold compress to the extremity intermittently

d. apply cold compresses to the extremity intermittently Cold minimizes swelling and erythema to the affected area. Therefore, the nurse should instruct the client to apply compresses for no more than 20 minutes at a time

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? a. have the client gently blow clots from the nose every 5 min b. instruct the client to sit with his head hyperextended c. apply ice compresses to the back of the client's neck d. apply lateral pressure to the client's nose for 10 min

d. apply lateral pressure to the client's nose for 10 min

a nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. which of the following actions should the nurse take first? a. instill proparacaine hydrochloride eye drops b. perform ocular irrigation of the right eye c. place the client in a supine position with the head turned toward the affected side d. ask the client about first aid performed at the scene

d. ask the client about first aid performed at the scene

a nurse is planning to administer diphenhydramine 50mg via IV bolus to a client who is having an allergic reaction. the client has an IV infusion containing a medication that is incompatible with the diphenhydramine in solution. which of the following actions should the nurse take? a. choose an IV port for IV bolus injection of diphenhydramine as near as possible to the client's hanging IV bag b. flush the IV tubing with 2mL of 0.9% sodium chloride before & after administering diphenhydramine c. allow the IV infusion to keep running while administering the diphenhydramine via IV bolus d. aspirate to check for V latency before administering the diphenhydramine

d. aspirate to check for IV latency before administering the diphenhydramine

A nurse is planning care for a client who has developed stomatitis. Which of the following interventions should the nurse include in the plan of care? a. rinse mouth with chlorhexidine solution every 2 hr b. limit fluid intake with meals c. provide oral hygiene with a firm bristle toothbrush after each meal d. avoid salty foods

d. avoid salty foods stomatitis is an inflammation of the mucosa of the mouth, usually with ulcerations. foods that are spicy, acidic, or salty should be avoided to prevent further irritation and damage to the oral mucosa

A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to the client who has a head injury with fixed, dilated pupils? a. red tag b. yellow tag c. green tag d. black tag

d. black tag the nurse should assign a black tag, or a class IV label, to client who are not expected to live and will be allowed to die naturally. dilated pupils that are fixed or nonreactive to light are a poor prognostic sign an indicate severely increased intracranial pressure. in a mass casualty situation, the overall goal is to provide lifesaving treatment to the greatest number of people possible

A nurse is caring for a client who is suspected to have tuberculosis. Which of the following findings should the nurse expect? a. recent weight gain b. high fever c. rhinitis d. blood-streaked sputum

d. blood-streaked sputum the nurse should expect blood-streaked sputum in a client who has tuberculosis. sputum cultures are used to diagnose pulmonary tuberculosis

A nurse is assessing a client who is experiencing perforation of peptic ulcer. Which of the following manifestations should the nurse expect? a. increased blood pressure b. decreased heart rate c. yellowing of the skin d. board-like abdomen

d. board-like abdomen the nurse should expect this client who is experiencing perforation of peptic ulcer to exhibit manifestations of a board-like abdomen and severe pain in the abdomen or back that radiates to the right shoulder. vomiting of blood and shock can occur if the perforation causes hemorrhaging

A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? a. chest pain is relieved soon after resting b. nitroglycerin relieves chest pain c. physical exertion does not precipitate chest pain d. chest pain lasts for longer than 15 min

d. chest pain lasts for longer than 15 min

a nurse is preparing to administer a tuberculin skin test to a client. after performing hand hygiene, which of the following actions should the nurse take? a. select a 23 gauge needle b. insert the needle into the skin at a 25 degree angle c. massage the area of injection following removal of the needle e d. circle the injection area with a pen

d. circle the injection area with a pen

A nurse is assessing a client who is receiving peritoneal dialysis. Which of the following findings should the nurse report to the provider immediately? a. difficulty draining the effluent b. redness at the access site c. fluid flowing from the catheter site d. cloudy effluent

d. cloudy effluent a cloudy or opaque effluent indicates the client is at high risk for peritonitis, a bacterial infection of the peritoneum. therefore, this is priority finding for the nurse to report to the provider

a nurse is caring for a client who has diverticulitis & a new prescription for a low fiber diet. which of the following food items should the nurse remove from the clients meal tray? a. canned fruit b. white bread c. broiled hamburger d. coleslaw

d. coleslaw

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? a. measuring heart rate b. palpating peripheral pulses c. observing sputum for blood d. confirming the gag reflex

d. confirming the gag reflex

a nurse is assessing an older adult client. which of the following findings should the nurse report to the provider? a. decreased cough reflex b. decreased urinary bladder capacity c. decreased sebum levels d. decreased spinal column movement

d. decreased spinal column movement

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate. After the nurse discontinues the client's urinary catheter, which of the following findings should the nurse report to the provider? a. pink-tinged urine b. report of burning upon urination c. stress incotinence d. decreased urine

d. decreased urine output A decrease in urine output after TURP indicates an obstruction to urine flow by a clot or residual prostatic tissue and should be reported to the provider

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? a. decreased capillary refill b. dyspnea c. orthopnea d. dependent edema

d. dependent edema

A nurse is teaching a client who has cirrhosis of the liver and a history of alcohol consumption. The nurse should explain that alcohol can cause liver cirrhosis through which of the following acitons? a. increasing the workload of the liver by replacing stored glycogen b. causing ulceration of liver tissue that can lead to bleeding c. dilating veins in the portal circulation d. destroying liver cells that are later replaced with scar tissue

d. destroying liver cells that are later replaced with scare tissue

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma. Which of the following pieces of information should the nurse include in the teaching? (select all that apply) a. lost vision can improve with eye drops b. administer eye drops as needed for vision loss c. glasses will be necessary to correct the accompanying presbyopia d. driving can be dangerous due to the loss of peripheral vision e. laser surgery can help reestablish the flow of aqueous humor

d. e.

A nurse is updating the plan of care for a client who has dumping syndrome. Which of the following instructions should the nurse include? a. consume beverages with meals b. eat 3 large meals per day c. include high-fiber foods in the diet d. eat a source of protein with each meal

d. eat a source of protein with each meal The nurse should include in the client's plan of care the instruction to eat a source of protein with each meal because protein delays gastric emptying

A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? a. maintain the client's knees and hips in a flexed position b. apply cold compresses to painful joints c. withhold opioids until the crisis is resolved d. encourage increased fluid intake

d. encourage increased fluid intake the nurse should encourage increased fluid intake to promote hydration because dehydration increased the viscosity of the blood, which can aggravate sickling and client discomfort

A nurse is reviewing the laboratory data of a client who reports manifestations suggesting systemic lupus erythematosus. The nurse should expect an increase in which of the following parameters for a client who has SLE? a. platelet count b. RBC count c. Hct d. erythrocyte sedimentation rate

d. erythrocyte sedimentation rate SLE is a chronic systemic autoimmune disease that causes skin, heart, lung, and kidney inflammation. like most autoimmune diseases, a series of exacerbations and remission is typical. most clients who has an exacerbation of SLE have an increased ESR

A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome? a. irregular cardiac rhythm b. numbness in the hands c. muscle cramps d. facial edema

d. facial edema

A nurse is reviewing the laboratory results of a client who has diabetes mellitus. Which of the following results indicates that the client's diabetes is controlled? a. HbA1c 8.5% b. postprandial blood glucose 190 mg/dL c. causal blood glucose 205 mg/dL d. fasting blood glucose 95 mg/dL

d. fasting blood glucose 95 mg/dL A fasting blood glucose of 95 mg/dL is within the expected reference range of 70 to 110 mg/dL, which indicates that this client's diabetes is under control

A nurse is caring for a client who is postoperative following a rhinoplasty. Which of the following findings should the nurse report to the surgeon? a. nasal edema b. mouth breathing c. periorbital ecchymosis d. frequent swallowing

d. frequent swallowing

A nurse is assessing a client who has osteoarthritis. The client's medical record indicates the presence of Heberden's nodes. Which of the following findings should the nurse expect? a. inflamed, fluid-filled sacs over the joints b. clubbing of the fingernails c. flexion contracture of the fingers d. hard lumps over the joints of the fingers

d. hard lumps over the joints of the fingers

A nurse is reviewing the medical record of a female client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? a. decreased intake of phosphate-containing foods b. spending several hours in the sun daily c. increased estrogen levels d. history of anorexia nervosa

d. history of anorexia nervosa

A nurse is assessing a client who has a complete intestinal obstruction. Which of the following findings should the nurse expect? a. absence of bowel sounds in all 4 abdominal quadrants b. passage of blood-tinges liquid stool c. presence of flatus d. hyperactive bowel sounds above the obstruction

d. hyperactive bowel sounds above the obstruction the nurse should expect the client to have hyperactive bowel sounds above the obstruction because the intestinal peristalsis above the obstruction attempts to push the obstruction through the intestines. With a complete intestinal obstruction, there are no bowel sounds below the obstruction

A nurse is reviewing the laboratory findings of a client who has chronic kidney disease. The client reports significant persistent nausea and muscle weakness. Which of the following findings should the nurse expect? a. hypernatremia b. hypomagnesemia c. hypercalcemia d. hyperkalemia

d. hyperkalemia a client who has chronic kidney disease can have hyperkalemia, which is a potassium level greater than 5.0 mEq/L. the expected reference range for potassium is 3.5-5.0 mEq/L. other manifestations of hyperkalemia can include palpitations, dysrhythmias, nausea, and muscle weakness

A nurse is monitoring a client who has Grave's disease for the development of thyroid storm. The nurse should report which of the following findings to the provider? a. cosntipation b. headache c. bradycardia d. hypertension

d. hypertension

A nurse is monitoring a client who has Graves' disease for the development of thyroid storm. The nurse should report which of the following findings to the provider? a. constipation b. headache c. bradycardia d. hypertension

d. hypertension a client who is experiencing a thyroid storm will have an exaggerated condition of hyperthyroidism associated with the development of a fever, hypertension, abdominal pain, and tachycardia. graves' disease is a common cause of hyperthyroidism, which is an imbalance of metabolism caused by overproduction of thyroid hormone

A nurse is caring for a client who has a cerebral lesion and develops hyperthermia. Which of the following areas of the client's brain is affected? a. Wernicke's area b. cerebral cortex c. basal ganglia d. hypothalamus

d. hypothalamus the nurse should identify that the hypothalamus, located below the cerebrum of the brain, is responsible for the regulation of body temperature

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take? a. place the drainage system at the head of the client's bed b. increase the suction to the chest drainage system c. place the client on low-flow oxygen via nasal cannula d. immerse the end of the chest tube in a bottle of sterile water

d. immerse the end of the chest tube in a bottle of sterile water

A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? a. question the client's coworker about the mechanism of injury b. check the client's pupils for equality and reaction to light c. measure the client's alertness using the GCS d. immobilize the client's cervical spine

d. immobilize the client's cervical spine

A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following findings of PVD is a risk factor for ulceration of the extremtities? a. insufficient skin care b. dehydration c. immobility d. impaired circulation

d. impaired cirulation

A nurse is teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse include? a. smoking cessation b. benefits of a diet high in cruciferous vegetables c. new types of ostomy appliances d. importance of colonoscopy screening starting at age 50 years old

d. importance of colonoscopy screening starting at age 50 years old

a nurse is preparing to administer oxytocin to a client who is at 41 weeks gestation & is experiencing ineffective labor. which of the following actions should the nurse plan to take? a. place the oxytocin from a pre filled syringe into the posterior fornix of the vagina every 10 minutes until effective labor occurs b. check the clients blood pressure & pulse every 15 minutes while induction of labor is occurring c. stop oxytocin for contractions that continue for more than 30 seconds d. increase the dose of oxytocin to obtain uterine contractions that occur every 2 to 3 minutes

d. increase the dose of oxytocin to obtain uterine contractions that occur every 2 to 3 minutes

A nurse is assessing a client who has manifestations of acromegaly. Which of the following findings should the nurse expect? a. thinning of skeletal bone structure b. concave chest wall c. high-pitched voice d. increased head size

d. increased head size

A nurse is monitoring the laboratory results of a client who has end-stage liver failure. Which of the following results should the nurse expect? a. decreased lactate dehydrogenase b. increased serum albumin c. decreased serum ammonia d. increased prothrombin time

d. increased prothrombin time client who have end-stage liver failure have an inadequate supply of clotting factors and an increased prothrombin time

A community health nurse is teaching a group of clients about melanoma. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching? a. one solid color b. symmetrical shape c. < 6 mm in diameter d. irregular border

d. irregular border

A nurse is preparing a plan of care for a client who is postoperative following a modified radial mastectomy. Which of the following invasive devices should the nurse expect the client to have? a. chest tube b. indwelling urinary catheter c. nasogastric tube d. jackson-pratt drain

d. jackson-pratt drain The nurse should expect this client who had a modified radial mastectomy to have 1 or 2 Jackson-Pratt drains. Jackson-Pratt drains are places under the skin flaps to promote drainage of fluid. Even for short hospital stays, the drains are usually kept in place for 1 to 3 weeks following discharge

A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? a. obtain coagulation laboratory studies from the client b. apply pneumatic compression boots to the client c. request a referral for a speech-language pathologist d. keep the client NPO

d. keep the client NPO

a nurse is assessing a client who has multidrbg-resistance tuberculosis & takes ethambutol. the nurse should identify which of the following findings as an adverse effect of this medication? a. mottling of the extremities b. orange-red urine & bodily secretions c. yellowing of the sclera d. loss of red/green color discrimination

d. loss of red/green color discrimination

A nurse is assessing a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction? a. bradycardia b. paresthesia c. hypertension d. low back pain

d. low back pain

A nurse is providing dietary teaching to a client who has dumping syndrome following gastric bypass surgery 4 days ago. Which of the following gastric bypass surgery 4 days ago. Which of the following recommendations should the nurse include in the teaching? a. avoid foods containing protein b. drink liquids during each meal c. eat foods that contain simple sugars d. maintain a supine position after meals

d. maintain a supine position after meals the nurse should instruct the client to lie supine after eating to help slow the rapid emptying of food into the small intestine. a client who has dumping syndrome should decrease the amount of food eaten at once, eat small meals more frequently, and eliminate fluids at mealtime. fluid shifts occur in the upper gastrointestinal tract when food content and simple sugars exit the stomach too rapidly, attracting fluid into the upper intestine and decreasing blood volume, which causes the client to experience nausea and vomiting, sweating, syncope, palpitations, increased heart rate, and hypotension

a charge nurse is monitoring a newly licensed nurse who is caring for a postoperative client who is receiving morphine through a PCA pump. which of the following actions by the newly licensed nurse requires intervention? a. instructing the client to administer a pea dose prior to a dressing change b. providing increased fluids while the client is on the pca pump c. informing the clients partner that only the client should administer the pca pump doses d. maintaining the client on bed rest while the pca pump is in use

d. maintaining the client on bed rest while the pca pump is in use

A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty with stent placement. Which of the following actions should the nurse anticipate in the post-procedure plan of care? a. instruct the client about a long-term cardiac conditioning program b. administer scheduled doses of acetaminophen c. check for peak laboratory markers of myocardial damage d. monitor for bleeding

d. monitor for bleeding

A nurse is planning care for a client following a stroke. Which of the following interventions should the nurse identify as the priority in the client's plan of care? a. prevent depression in the client b. refer the client to occupational therapy c. support the client's family d. monitor the client for increased intracranial pressure

d. monitor the client for increased intracranial pressure

A nurse is planning care for a client who is experiencing the Somogyi effect and take intermittent-acting insulin. Which of the following actions should the nurse include in the plan? a. move the evening intermediate-acting insulin dose to 90 min before dinner b. increase the client's morning caloric intake c. omit the client's evening snack d. monitor the client's nighttime blood glucose levels

d. monitor the client's nighttime blood glucose levels

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease. Which of the following oxygen-delivery methods should the nurse plan to use for this client? a. simple face mask b. nonrebreather mask c. bag-valve mask device d. nasal cannula

d. nasal cannula

A nurse is assessing a client who has acute kidney injury. According tot he RIFLE classification system, which of the following findings indicates that the client has end-stage kidney disease? a. <0.5 mL/kg of urine output for 12 hr b. no urine output for 12 hr c. no urine output without renal replacement therapy for 4-12 weeks d. no urine output without renal replacement therapy for more than 3 months

d. no urine output without renal replacement therapy for more than 3 months

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? a. soft blowing b. loud bubbling c. dry grating d. noisy wheezing

d. noisy wheezing Asthma causes the bronchioles of the lungs to constrict, creating a wheezing sound

A nurse is caring for a client who is receiving radiation therapy for breast cancer and reports a metallic taste in the mouth. Which of the following dietary recommendations should the nurse share with the client? a. eat with metal utensils b. limit coffee c. avoid citrus foods d. offer mints

d. offer mints

a nurse is caring for a client who is taking a prescription for glucocorticoid adrenal placement medication for the long term treatment of Addison's disease. which of the following findings indicates that the client is experiencing an adverse effect of the medications? a. weight loss b. hypotension c. lethargy d. osteoporosis

d. osteoporosis

A nurse is caring for a client who has urolithiasis and requires further diagnostic testing after an initial test indicated hypercalcemia. Which of the following structures controls calcium? a. pancreas b. thyroid gland c. anterior pituitary gland d. parathyroid gland

d. parathyroid gland

A nurse is planning an in-service training session for a group of nurses regarding the role of enzymes in digestion. Which of the following enzymes plays a role in the digestion of protein? a. amylase b. lipase c. steapsin d. pepsin

d. pepsin pepsin is an enzyme secreted by the gastric mucosa that breaks down protein into polypeptides. other enzymes such as trypsin and aminopeptidase further break down the polypeptides into amino acids, which can be used by the body

A nurse is teaching a client who has osteoporosis. Which of the following instructions should the nurse include int he teaching? a. reduce dietary protein intake b. apply ice to painful areas c. increase calcium intake to 900 mg per day d. perform weight-bearing exercises

d. perform weight-bearing exercises

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following adverse affects? a. diarrhea b. increased serum albumin c. hypoglycemia d. peritonitis

d. peritonitis peritonitis is an adverse effect of peritoneal dialysis. prevent requires using sterile techniques and frequently assessing the catheter exit site. The nurse should obtain cultures of the dialysate outflow if peritonitis is suspected

A nurse is caring for a client who is concerned about the possibility of contracting Lyme disease after receiving a tick bite. For which of the following early manifestations of Lyme disease should the nurse assess the client? a. diffuse maculopapular rash b. dyspnea c. double vision d. progressive circular rash

d. progressive circular rash Early Lyme disease is characterized by a fever, influenza-like manifestations, and erythema migrans, which is a distinct, progressive, circular or bullseye rash that often develops at the bite site but can also develop at other sites such as the thighs and knees

A nurse is caring for a client who will receive brachytherapy to treat uterine cancer. The nurse should ensure the client understands that she will receive which of the following interventions? a. chemotherapy via a central venous access device b. radiation to the tumor from an external source c. precise delivery of high-dose radiation after tumor imaging d. radioactive infusions or insertions into or near the tumor

d. radioactive infusions or insertions into or near the tumor brachytherapy is a type of radiation therapy during which the radiation source, either an implant or via infusion is in direct contact with the client's tumor continuously for a specific duration

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty? a. finding the bathroom in the dark b. driving at night c. seeing numbers on highway signs d. reading the newspaper

d. reading the newspaper with presbyopia, the lens is unable to change shape to focus on near object. presbyopia develops with aging, beginning in middle age, and results from the decreased elasticity of the lens

A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? a. nonproductive cough, fever, and shortness of breath b. lesions on the retina that produce blurred vision c. onset of progressive dementia d. reddish-purple skin lesions

d. reddish-purple skin lesions Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following a biopsy, the lesions are treated with radiation and/or chemotherapy

A nurse is caring for a client who has dementia and is experiencing anxiety. Which of the following actions should the nurse take? a. place a vest restraint on the client to protect others in the environment b. provide a variety of routines to keep the client from getting bored c. explain to the client that episodes of anxiety will decrease over time d. redirect the client to a different activity with a small group of people

d. redirect the client to a different activity with a small group of people

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestations of autonomic dysreflexia? a. flushing of the lower extremities b. hypotension c. tachycardia d. report of a headache

d. report of a headache autonomic dysreflexia is a neurological emergency that can occur in clients who has a cervical or thoracic spinal cord injury above the level of T6

A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications? a. pulmonary edema b. tension pneumothorax c. flail chest d. respiratory obstruction

d. respiratory obstruction

A nurse in the PACU is assessing a newly admitted client and observes intercoastal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications? a. pulmonary edema b. tensions pneumothorax c. flail chest d. respiratory obstruction

d. respiratory obstruction intercostal retractions and a high-pitched inspiratory noise are manifestations of an airway obstruction caused by laryngospasm and edema. The nurse should notify the rapid response team and plan to administer racemic epinenphrine

A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect? a. spasticity of the left foot b. negative babinski reflex c. ocular hypertension d. right-sided hemiplegia

d. right-sided hemiplegia

A nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. Which of the following pieces of information in the client's medical record should the nurse identify as a risk factor for tinnitus? a. use of hydrochlorothiazide b. chronic use of acetaminophen c. allergic external otitis d. sclerosis of the ossicles

d. sclerosis of the ossicles

A nurse is providing teaching to a client who has a new diagnosis of myasthenia gravis. Which of the following pieces of information should the nurse include? a. use enemas to treat constipation caused by daily medications b. take a hot bath when muscles ache c. eat a low-calorie diet d. set an alarm to ensure medication dosages are taken on time

d. set an alarm to ensure medication dosages are taken on time the nurse should instruct the client to take medication dosages on time to maintain a therapeutic blood level. dosages should not be missed or postponed because this can cause an exacerbation of the disease

A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI? a. blood urea nitrogen (BUN) b. blood glucose c. urine ketones d. specific gravity

d. specific gravity

A nurse is planning care for a client who has been admitted for the treatment of a malignant melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for which of the following procedures? a. curettage b. external radiation therapy c. regional chemotherapy d. surgical excision

d. surgical excision the therapeutic approach to malignant melanoma depends on the level of invasion and the depth of the lesion. surgical excision is the treatment of choice for small, superficial lesions. deeper lesions require wide local excision, followed by skin grafting

A nurse is performing a gastrointestinal assessment of a client who has liver cirrhosis with abdominal distention. Which of the following actions should the nurse take to assess for changes in the client's abdominal distention? a. percuss the abdomen for tympanic sounds b. inspect the contour of the abdominal wall c. instruct the client to report increased abdominal discomfort d. take serial measurements of the abdomen with a tape measure

d. take serial measurements of the abdomen with a tape measure

a nurse is teaching a client who is taking levothyroxine for hypothyroidism about a new prescription for a calcium supplement. which of the following pieces of information should the nurse include? a. the calcium supplement will enhance the effect of the levothyroxine b. the calcium supplement will accelerate the metabolism of the levothyroxine c. take the medications together at 1700 for the greatest effect d. take the calcium supplement 4 hours after taking the levothyroxine

d. take the calcium supplement 4 hours after taking the levothyroxine

A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? a. edema in the burned extremities b. severe pain at the burn sites c. urine output of 30 mL/hr d. temperature of 102.4

d. temperature of 102.4 an elevated temperature is an indication of infection, and the nurse should report this findings to the provider. sepsis is a critical findings following a major burn injury. initially, burn wounds are relatively pathogen-free. on approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging examination of the cervical vertebra. Which of the following pieces of information in the client's history is a contraindication to this procedure? a. the client has a new tattoo b. the client is unable to sit upright c. the client has a history of peripheral vascular disease d. the client has a pacemaker

d. the client has a pacemaker

a nurse is preparing to administer an afternoon dose of ampicillin to a client. the client appears upset & refuses to take the medication before throwing the pill on the floor. which of the following entries should the nurse enter into the client's medical record? a. the client refused to take medication today b. the client stated I will not take this pill c. the client seemed angry & hostile d. the client threw the medication on the floor

d. the client threw the medication on the floor

the nurse is preparing to administer an afternoon dose of ampicillin to a client. the client appears upset & refuses to take the medication before throwing the pill on the floor. which of the following entries should the nurse enter into the client's medical record? a. the client refused to take the medication today b. the client stated "I will not take this pill" c. the client seemed angry & hostile d. the client therew the medication on the floor

d. the client threw the medication on the floor

a nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 ml/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention? a. a full pitcher of water is sitting on the client's bedside table within the client's reach b. the disposable feeding bag is from the previous day at 1000 and contained 200 mL of feeding c. the client is lying on the right side with a visible dependent loop in the feeding tube d. the head of the bed is elevated to 20 degrees

d. the head of the bed is elevated to 20 degrees

A nurse is reviewing the progress notes for a client who has heart failure. The provider noted some improvement in the client's cardiac output. The nurse should understand that cardiac output reflects which of the following physiologic parameters? a. the percentage of blood the ventricles pump during each beat b. the amount of blood the left ventricle pumps during each beat c. the amount of blood in the left ventricle at the end of diastole d. the heart rate times the stroke volume

d. the heart rate times the stroke volume cardiac output is the product of the client's heart rate and stroke volume

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following indicates that the nurse should suction the client's airway secretions? a. the client is unable to speak b. the client's airway secretions were last suctioned 2 hr ago c. the client coughs and expectorates a large mucous plug d. the nurse auscultates coarse crackles in the lung fields

d. the nurse auscultates coarse crackles in the lung fields the nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication? a. hallucinations b. pruritus c. hand and foot syndrome d. tinnitus

d. tinnitus

A nurse is preparing an in-service presentation about the basics of hematology. Which of the following factors provides a stimulus for the production of RBCs? a. venous stasis b. thrombocytopenia c. inflammaiton d. tissue hypoxia

d. tissue hypoxia in response to tissue hypoxia, the kidneys release erythropoietin, which stimulates the production of erythrocytes in the bone marrow

A nurse is preparing to administer a Mantoux skin test a client. What is the purpose of a Mantoux skin test using purified protein derivative (PPD)? a. to identify if a client lacks immunity to tuberculosis b. to find out if a client ahs active tuberculosis c. to decrease the hypersensitivity of the client's reaction to PPD d. to identify if a client has been infected with mycobacterium tuberculosis

d. to identify if a client has been infected with mycobacterium tuberculosis the nurse should inform the client that the Mantoux skin test is used to identify individuals who have been infected with Mycobacterium tuberculosis

A nurse enters a client's room and notes smoke coming from a wastebasket in the adjacent bathroom. Which of the following actions should the nurse take first? a. close the door to the client's room b. attempt to extinguish the fire c. activate the facility's fire alarm system d. transport the client to an area away from the smoke

d. transport the client to an area away from the smoke

A nurse is caring for a client who is receiving radiation therapy for mouth cancer and reports a dry mouth. Which of the following dietary recommendations should the nurse provide? a. offer graham crackers b. avoid foods containing citrus c. rinse the mouth with an alcohol-based mouthwash before eating d. use gravies or sauces to soften food

d. use gravies or gravies to soften food

a nurse is preparing to administer an intramuscular injection to a young adult client. which of the following injection sites is the safest for this client? a. vastus lateralis b. dorsogluteal c. deltoid d. ventrogluteal

d. ventrogluteal

A nurse is caring for a client who has pernicious anemia. Which of the following factors should the nurse identify with this condition? a. iron deficiency b. hemolytic blood loss c. folic acid deficiency d. vitamin B12

d. vitamin B12 deficiency a client who has pernicious anemia is deficient in vitamin B12 due to a deficiency in an intrinsic factor normally supplied by the gastric mucosa that is essential for the absorption of vitamin b12

A nurse is providing teaching to the guardian of a child who has celiac disease. Which of the following foods should the nurse instruct the guardian to omit from the child's diet? a. cornflakes b. reduced-fat milk c. canned fruits d. wheat bread

d. wheat bread

A nurse is admitting a client who has multiple myeloma and a white blood cell count of 2,200/mm^3. Which of the following foods should the nurse prohibit the family members from bringing to the client? a. fried chicken from a fast food restaurant b. a case of canned nutritional supplements c. a factory-sealed box of chocolates d. a fresh fruit basket

raw fruits and vegetables are contraindicated for a client who has neutropenia, as the skin of these food items might harbor bacteria that can cause infection