Care Management 2 Final Review

A patient has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition?

-acupuncture -stretching -tai chi

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease?

-antibodies lead to inflammation -it consists of an autoimmune process

What actions by the circulating nurse are important to promote patient comfort?

-correct positioning -remaining present -providing warmth -introducing one's self

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve the goal?

-disposing of dressings properly -removing and replacing wet dressings -performing proper heand hygiene

A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include?

lying on the unaffected side can prevent complications

The nurse understands that which type of immunity is the longest acting?

natural active immunity

A nurse is providing discharge teaching for a client who underwent foot surgery. The nurse is collaborating with the occupational therapist and discussing the use of assistive devices. On what variables does the choice of assistive devices primarily depend?

patient's general condition, balance, and weight-bearing prescription

A nurse is assessing a client who reports ear pain for the past days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions?

perforated tympanic membrane

A patient has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?

purulent drainage

The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system?

red marrow

A patient is undergoing computed tomography (CT) of a joint. What action by the nurse is the most important before the test?

assess for seafood or iodine allergy

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing?

-infection -serious cardiac events -thromboembolism

The nurse is reviewing possible complications from a phalloplasty. What factors does the nurse include?

-infection of donor site -necrosis of the neopenis -urinart tract stenosis

A nursing student studying the musculoskeletal system learns about important related hormones. What information does the student learn?

-lack of Vit D can lead to rickets -estrogens stimulate osteoblastic activity -parathyroid hormone stimulates osteoclastic activity

A nurse works with many transgender patients. What routine monitoring is important for the nurse to facilitate in this population?

-lipid profile -liver function test -mammograms if breast tissue is present -prostate-specific antigen (PSA)

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include?

-liver biopsy: diagnostic -total shoulder replacement: restorative

A client is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results is most suggestive of this diagnosis?

-low serum calcium -low phosphorus

When implementing a comprehensive plan to reduce the incidence of falls on a gerontologic unit, what risk factors should the nurse identify?

-medication effects -poor lighting -sensory impairment

A nurse cares for a patient with elevated triiodothyronine and thyroxine, and normal thyroid-stimulating hormone levels. What actions does the nurse take?

-monitor the apical pulse -initiate telemetry monitoring

A patient reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. Which actions by the nurse are most appropriate?

-notify the nurse manager of the physician's request -consult with the prescriber and voice objections

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern?

-pinpoint pupil -absence of pupillary response -unequal pupil

A patient with a broken arm has had ice placed on it for 20 minutes. A short time after the ice was removed, the patient reports that the effect has worn off and requests pain medication, which cannot be given yet. Which actions by the nurse are most appropriate?

-repeat the ice application -teach the patient relaxation techniques -educate the patient on cold therapy

A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover?

-strengthening exercises are important -take recommended calcium & vit D -walk 30 minutes at least 3 times a week

A nurse provides diabetic education at a public health fair. Which disorders would the nurse include as complications of diabetes mellitus?

-stroke -kidney failure -blindness

A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct does at 0715, the nurse should ensure the client receives breakfast at which of the following times?

0745

A nurse teaches a patient about prosthesis care after amputation. Which statements would the nurse include in this patient's teaching?

-the device has been custom made specifically for you -make sure that you wear the correct liners with your prosthetic -i have scheduled a follow up appointment for you

A nurse cares for a patient with a hypofunctioning anterior pituitary gland. Which hormones would the nurse expect to be affected by this condition?

-thyroid stimulating hormone -follicle stimulating hormone -growth hormone

A faculty member explains the concepts of addiction, tolerance, and dependence to student. Which information is accurate?

-tolerance is a normal response to regular opioid use -tolerance is said to occur when opioid effects decrease -addiction is a chronic physiologic disease process

The circulating nurse reviews the day's schedule and notes patients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which patient does the include?

-young male patient w/ a RYR1 gene mutation -a 75-year-old patient scheduled for an elective procedure -patient who drinks a 6 pack of beer each day -patient with a serum creatinine of 3.8 mg/dL

Ten hours after surgery, a postoperative patient reports that the anti-embolism stockings and sequential compression devices itch and are too hot. The patient asks the nurse to remove them. What response by the nurse is best?

to prevent blood clots, you need them a few more hours

After a vaginoplasty, what instruction by the nurse is most important?

you must dilate the vagina several times a day for months

A nurse assesses a patient on the medical-surgical unit. Which statement made by the patient alerts the nurse to assess the patient for hypothyroidism?

I am always tired, even with 12 hours of sleep

A nurse has educated a patient on an epinephrine auto-injector (EpiPen). What statement by the patient indicates additional instruction is needed?

I don't need to go to the hospital after using it

A nurse is caring for a client who has developed agranulocytosis as a result of taking propylthoiouracil to treat hyperthyroidism. The nurse should understand that this client is at increased risk for which of the following conditions?

infection

A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temperature is 39 degrees C (102.2 degrees F) orally. Which of the following actions should the nurse take?

inform the surgeon of the elevated temperature

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?

inform the surgeon that the sterile field has been broken

A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered?

insertion of a ventilation tube

A patient comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the patient for Heberden's nodules. What assessment technique is correct?

inspect the client's distal finger joints

A patient having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important?

instruct the client not to get up without help

The nurse's comprehensive assessment of an older adult involves the assessment of the client's gait. How should the nurse best perform this assessment?

instruct the client to walk away from the nurse for a short distance and then toward the nurse

A nurse is providing teaching to a client who has a new diagnosis of hypothyroidism. On which of the following medications should the nurse prepare to instruct the client?

levothyroxine

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)?

lose weight if needed

The nurse is providing care for an 82-year-old man whose signs and symptoms of Parkinson disease have worsened over the past several months. The man states that he can no longer do as many things for himself as he used to be able to. What factor should the nurse recognize as impacting the client's life most significantly?

loss of independence

A patient has been prescribed denosumab (Prolia). What instruction about this drug is most important?

make appointments to come get your shot

A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority?

monitor the client for hypoglycemia

A nurse teaches a patient with diabetes mellitus about sick-day management. Which state would the nurse include in this patient's teaching?

monitor your blood glucose levels at least every 4 hours while sick

A patient has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important?

notify your provider at once if you get a fever

A patient is admitted with a large draining wound on the leg. What action does the nurse take first?

obtain cultures of the leg wound

A nurse is caring for a patient who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The patient's symptoms have now resolved and the patient asks, "When can I stop taking these medications?" How would the nurse respond?

once you start corticosteroids, you have to be weaned off them

A child is growing at a rate appropriate for his age. What cells are responsible for the secretion of bone matrix that eventually results in bone growth?

osteoblasts

A patient is hospitalized with Pneumocystis jiroveci pneumonia. The patient reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort?

pace activities, allowing for adequate rest

The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of this diagnosis?

pain on manipulation of the auricle

The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan his client care with the knowledge that his surgical procedure is classified as which of the following?

palliative

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

perform a Romberg's test

What nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture?

place a pillow between the client's leg when turning

A nurse is caring for a client who has right-sided acoustic neuromas resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

place suction equipment at the client's bedside

A patient with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action would the nurse take first?

place the client under airborne precautions

A nurse is caring for the client who has Meniere's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?

please call for assistance when you wish to get out of bed

A nurse is caring for four patients. After the hand-off report, which does the nurse see first?

post-microvascular bone transfer client whose distal leg is cool and pale

A client is involved in a motorcycle accident and injures his arm. The physician diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this client. What sequela of intra-articular fractures should the nurse describe regarding this client?

post-traumatic arthritis

The student nurse learns that the most important function of inflammation and immunity is which purpose?

providing protection against invading organisms

A transgender patient is taking transdermal estrogen (Climara). What assessment finding does the nurse report immediately to the provider?

red, swollen calf

A patient is preparing for gender reassignment surgery and will transition from male to female. The patient is worried about the voice not sounding feminine enough. What action by the nurse is best?

refer the client for vocal therapy with speech-language pathology

A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

restrict head movement

A nurse cares for a patient who is prescribed pioglitazone (Actos). After 6 months of therapy, the patient reports that his urine has become darker since starting the medication. What action would the nurse take?

review the client's liver function study results

A client presents at a clinic complaining of back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?

sciatica

A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN?

securing the drain's safety pin to the sheets

A nurse reviews the laboratory results of a patient who is receiving intravenous insulin. Which would alert the nurse to intervene immediately?

serum potassium level of 2.5 mmol/L

After teaching a patient who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional teaching?

since my diabetes is controlled with diet and exercise, I must be seen only if I am sick

A nurse cares for a patient in skeletal traction. The patient asks, "What is the primary purpose of this type of traction?" How would the nurse respond?

skeletal traction will assist in realigning your fractured bone

A nurse is providing a class on osteoporosis at the local seniors' center. Which of the following statements related to osteoporosis is most accurate?

slow discontinuation of corticosteroid therapy can halt the progression of the osteoporosis

The nurse working with patients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem?

suppressor T cells

A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care?

surgical intervention

A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect?

tachycardia

A nurse assesses a patient who is recovering from a transsphenoidal hypophysectomy. The nurse notes nuchal rigidity. What action would the nurse take first?

take vital signs, including temperature

A patient has just returned from a right radical mastectomy. Which action by the unlicensed assistive personnel (UAP) would the nurse consider unsafe?

taking the blood pressure on the right arm

A client is scheduled for a bone scan to rule out osteosarcoma of the pelvic bones. What would be most important for the nurse to assess before the client's scan?

that the patient emptied the bladder

A hospitalized patient's strength of the upper extremities is rated at 3. What does the nurse understand about his patient's ability to perform activities of daily living (ADLs).

the client is able to perfom ADLs but not lift some items

A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse for following surgical removal of a cataract. Which of the following should the nurse include in the teaching?

the client should wear dark glasses while outdoors

The nurse is discussing the results of a client's diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss?

the sound is heard better in the ear in which hearing is better

A patient has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The patient calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best?

this drug works in the brain to decrease pain

A nurse cares for an older adult patient who is recovering from a leg amputation surgery. The patient states, "I don't want to live with only one leg. I should have died during the surgery." How would the nurse respond?

this is a big change for you. what support system do you have to help you cope

A client is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. What is the most plausible explanation for this client's signs and symptoms?

traumatic hip dislocation

A patient has rheumatoid arthritis that especially affects the hands. The patient wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best?

try a paraffin wax dip 20 minutes before you quilt

A nurse is caring for a client in skin traction. In order to prevent bony fragments from moving against one another, the nurse should caution the client against performing what action?

turning side to side

A nurse is preparing to give a patient ketorolac (Toradol) intravenously for pain. Which assessment findings would lead the nurse to consult with the provider?

urine output of 20 mL/2hr

A 91-year-old client is slated for orthopedic surgery and the nurse is integrating gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client?

use of a pressure-relieving mattress

An HIV-positive patient is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate?

use standard precautions consistently

A nurse is preparing to discharge an emergency department client who has been fitted with a sling to support her arm after a clavicle fracture. What should the nurse instruct the client to do?

use the arm for light activities within the range of motion

A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect?

vertigo

A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include?

vision will be greatly improved on the day of surgery

The nurse working in the rheumatology clinic is seeing patients with rheumatoid arthritis (RA). What assessment would be most important for the patient whose chart contains the diagnosis of Sjogren's syndrome?

visual acuity

A patient calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?

will not provide relief

A nurse cares for a patient who had a wrist case applied 3 days ago. The patient states, "The cast is loose enough to slide off." How would the nurse respond?

you need a new cast now that the swelling is decreased

A nurse cares for a patient who has hypothyroidism as a result of Hashimoto's thyroiditis. The patient asks, "How long will I need to take thy thyroid mediation?" How does the nurse respond?

you'll need thyroid pills for life because your thyroid won't start working again

A patient had a bunionectomy with osteotomy. The patient asks why healing may take up to 3 months. What explanation by the nurse is best?

your feet have less blood flow, so healing is slower

A nurse assesses patient with potential disorder. What patients are at high risk for adrenal insufficiency?

-a 22 yr old female w/ metastatic cancer -a 43 yr old male with tuberculosis -a 65 yr old male with gram-negative sepsis

A nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse should identify which of the following findings as an indication that the medication is effective?

a decrease in urine output

The nurse is caring for a patient diagnosed with human immune deficiency virus. The patient's CD4+ cell count is 399/mm3. What action by the nurse is best?

counsel the client on safer sex practices/abstinence

A nurse is assessing a patient for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider?

creatinine of 3.9 mg/dL

A -month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear?

gray

Radiographs of a boy's upper arm show that the humorous appears to be fractures on one side and slightly bent on the other. This diagnostic result suggest what type of fracture?

greenstick

A medical nurse is providing palliative care to a client with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurse's care?

to improve the patient's and family's quality of life

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?

I need something for the horrible pain in my eye

The clinic nurse assesses a patient with diabetes during a checkup. The patient also has osteoarthritis (OA). The nurse notes the patient's blood glucose readings have been elevated. What question by the nurse is most appropriate?

have you been taking glucosamine supplements

A patient with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply?

ice packs

After teaching a patient who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the patient's understanding. Which statement made by the patient indicates a correct understanding of the teaching?

I should look into swimming or water aerobic to get my exercise

A nurse is discharging a patient after a total hip replacement. What statement by the patient indicates good potential for self-management?

I will not sit with my legs crossed

A nurse is providing teaching to a client who has a new prescription for levothyroxine for hypothyroidism. The nurse should instruct the client to avoid which of the following herbal supplements?

Soy

The nurse is employed in a neurologist's office, performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?

VIII

The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ?

identical twin

A postoperative nurse is caring for a patient who receives a neuromuscular blocking agent during surgery. Which assessment by the nurse is most important?

abdominal breathing pattern

A nurse in the family clinic is teaching a patient newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching?

acetaminophen (Tylenol)

A patient with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this patient and family?

adherence to the antibiotic regimen, eating high protein and high carb

A nurse assesses a patient with a rotator cuff injury. Which finding would the nurse expect to assess?

inability to initiate or maintain abduction of the affected arm at the shoulder

The orthopedic surgeon has prescribed balanced skeletal traction for a client. What advantage is conferred by balance traction?

balanced traction allows for greater patient movement and independence than other forms of traction

A clinic nurse is caring for a client with a history of osteoporosis. What diagnostic test will best allow the care team to assess the client's risk of fracture?

bone densitometry

A client is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur?

buck's extension

A nurse is reviewing the pathophysiology that may underlie a client's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation?

calcitonin

A nurse works in the rheumatology clinic and sees patients with rheumatoid arthritis (RA). Which patient would the nurse see first?

client with a red, hot, swollen right wrist

The nurse providing direct patient care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from patients. Which practice is most effective?

consistent use of standard precautions

A client has been admitted to the hospital with a spontaneous vertebral fracture related to osteoporosis. Which of the following nursing diagnoses must be addressed in the plan of care?

constipation r/t vertebral fracture

A patient takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The patient also requests the celecoxib in addition to the morphine. What action by the nurse is best?

consult with the health care provider about administering both drugs to the client

A patient with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important?

consult with the pharmacy about drug interactions

A client has had a cast placed for the treatment of a humeral fracture. The nurse's most recent assessment shows signs and symptoms of compartment syndrome. What is the nurse's most appropriate action?

contact the primary provider immediately

A nurse is reviewing the medical record of a client who has been on levothyroxine for several months. Which of the following findings indicate a therapeutic response to the medication?

decrease in level of thyroid stimulating hormone (TSH)

A 84-year-old client has returned from the post-anesthetic care unit (PACU) following hip arthroplasty. The client is oriented to name only. The client's family is very upset because, before having surgery, the client has no cognitive deficits. The client is subsequently diagnosed with postoperative delirium. What should the nurse explain to the client's family?

delirium of this type is treatable and her cognition will return to pervious levels

A nurse plans care for a patient with hypothyroidism. Which priority problem does the nurse address first for this patient?

depression and withdrawal

What information does the nurse teach a women's group about osteoporosis?

for 5 yrs after menopause you lose 2% of bone mass yearly

A nurse working in the preoperative holding area performs which function to ensure patient safety?

-have the patient help mark the surgical site -ensure that the patient has an armband on -check that consent is on the chart -allow the patient to use the toilet before giving sedation

A nurse is talking with a client whose thyroid-stimulating hormone (TSH) level will be measures. Which of the following statements by the nurse explains the purpose of this test?

"this test determines whether your thyroid gland is overactive, appropriately active, or underactive"

A patient has been educated on sirolimus (Rapamune). What statements indicate that this education was effective?

-i should avoid large crowds and sick people -i need to use two form of birth control and not get pregnant

A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn?

-eosinophils increase during allergic reactions & parasitic invasion -macrophages can participate in many episodes of phagocytosis -monocytes turn into macrophages after they enter body tissue -neutrophils can only take part in one episode of phagocytosis

The admissions department at the local hospital is registering a male older adult for an outpatient diagnostic test. The admissions nurse asks the man if he has an advanced directive. The man responds that he does not want to complete an advance directive because he does not want anyone controlling his finances. What would be appropriate information for the nurse to share with this client?

"advanced directives are limited only to health care instructions and directives"

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components?

-alcohol -caffeine -carbonated beverages -vit D

A patient with fibromyalgia is in the hospital for an unrelated issue. The patient reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate?

-allow the client uninterrupted rest time -assess the client's usual bedtime routine -limit environmental noise as much as possible -offer a massage or warm shower at night

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia?

-blurred vision -tachycardia -moist, clammy skin

A nurse is providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nurtients?

-calcium -vit D

The nurse is assessing a patient for chronic osteomyelitis. Which features distinguish this from the acute form of the disease?

-draining sinus tracts -presence of foot ulcers

A patient has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the patient to maintain independence in activities of daily living (ADLs)?

-grab bars to reach high items -long-handled bath scrub brush -toothbrush with built up handle

A nurse assesses patients for potential endocrine dysfunction. Which patient is at greatest risk for a deficiency of gonadotropin and growth hormone?

a 42 yrs old male who experienced head trauma 3 years ago

A trauma nurse cares for several patients with fractures. Which patient would the nurse identify as at highest risk for developing deep vein thrombosis?

a 74-yr-old man who smokes and has a fractured pelvis

A student is caring for patients in the preoperative area. The nurse contacts the surgeon about a patient whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta-blocker to the patient. The student asks why this was needed. What response by the nurse is best?

a rapid heart rate requires more effort by the heart

At 4:45 PM, a nurse assesses a patient with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the patient is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below. After reviewing the patient's assessment data, which action is appropriate at this time?

administer dextrose 50% intravenously and reassess the client

The nurse is presenting information to a community group on safer sex practices. The nurse would teach that which sexual practice is the riskiest?

anal intercourse

A physician writes a prescription to discontinue skeletal traction on an orthopedic client. The nurse should anticipate what subsequent intervention?

application of a cast

A client has informed the home health nurse that she has recently noticed distortions when she looks at the Amsler grid that she has mounted on her refrigerator. What is the nurse's most appropriate action?

arrange for the client to be assessed for macular degeneration

A nurse is reviewing the chart of a new patient in the family medicine clinic and notes that the patient is identified as "George Smith". The nurse enters the room and finds a woman in a skirt. What action by the nurse is best?

ask the client about preferred forms of address

A patient is distressed at body changes related to kyphosis. What response by the nurse is best?

ask the client to explain more about these feelings

A patient who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best?

assess medication records for steroid use

A patient with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action would the nurse take first?

assess the client for adherence to the drug regimen

A patient is in the internal medicine clinic reporting bone pain in the lower leg. The patient's alkaline phosphate level is elevated. What action by the nurse is most appropriate?

assess the client for leg bowing

A patient in the orthopedic clinic has a self-reported history of osteoarthritis. The patient reports a low-grade fever that started when the weather changed and several joints started "acting up", especially both hips and knees. What action by the nurse is best?

assess the client for the presence of subcutaneous nodules or Baker's cysts

A nurse is talking with a patient about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the patient states "Whew? I was really worried about that result." What action by the nurse is most important?

assess the client's sexual activity and patterns

An emergency department nurse cares for a patient who sustained a crush injury to the right lower leg. The patient reports numbness and tingling in the affected leg. Which action would the nurse take first?

assess the pedal pulses

A patient with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition?

assessing mucous membranes

The nurse is working with a patient who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the patient. What finding by the nurse indicates goals for this patient problem are being met?

attends meetings of a book club

A nurse is working for a home health agency is teaching a client who has diabetes mellitus about disease management. Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels?

average blood glucose for approx. 90-120 days

A patient is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important?

avoid large crowds and people who are ill

A client has sustained traumatic injuries that involve several bone fractures. A fracture of what type of bone may interfere with the protection of the client's vital organs?

flat bones

A patient is started on etanercept (Enbrel). What teaching by the nurse is most appropriate?

giving subcutaneous injections

The nurse is caring for patients on the medical-surgical unit. What action by the nurse will help prevent a patient from having type II hypersensitivity reaction?

correctly identifying the client prior to a blood transfusion

A patient has been on dialysis for many years and now is receiving a kidney transplant. The patient experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?

dialysis

A nurse is teaching a client how to draw up regular insulin and NPH insulin into the same syringe. Which of the following instructions should the nurse include?

discard regular insulin that appears cloudy

A patient with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important?

disposing of soiled dressings properly

A client's ocular tumor has necessitated enucleation and the client will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the client's discharge education?

disturbed body image

A nurse is caring for a client who has a leg cast. The nurse observes that the client uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation?

encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists

A nurse on the postoperative unit administers many opioid analgesics. Which actions by the nurse are best to prevent unwanted sedation as a complication of these medications?

-avoid using other medications that cause sedation -give the lowest does that produces good control -use an oximeter to monitor patients receiving analgesia -identify patients at high risk for unwanted sedation

A nurse is assessing a client's lab values before surgery. Which of the following results should the nurse report to the provider?

-creatinine 2.8 mg/dL -blood glucose 235 mg/dL -WBC 17,850/mm3

A student nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem?

-decreased immune response -possible immobility -slower healing -development of chronic pain

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give?

-decreased oxygenation -decreased cardiac output -frequent nocturia -mobility alterations

A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which manifestations would the nurse monitor the patient?

-deep & fast respirations -tachycardia -orthostatic hypotension

A nurse teaches a patient who is prescribed an unsealed radioactive isotope. Which statements will the nurse include in this patient's education?

-do not share utensils, plates, and cups w/ anyone else -wash your clothing separate from others in the household -take a laxative 2 days after therapy to excrete the radiation

The nurse student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles?

-ensuring the patient's safety -monitoring traffic in the room

A nurse is reviewing the medical records of several clients in the PACU to identify risk factors that can lead to postop complications. Which of the following clients are at risk for complications?

-a client who takes warfarin daily -a client who uses an insulin pump -a client with a WBC of 22,500/uL -a client who has heart failure

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care?

-assist with early ambulation -reposition the client every 2 hr -instruct the client to splint the incision when coughing and deep breathing -encourage use of the incentive spirometer every 2 hr

A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve that goal?

-attend hand-off rounds to coach and mentor -conduct audits of staff using a new template -create a template of topics to include in report -encourage staff to ask questions during hand-off

A nurse assesses a patient with Cushing's disease. Which assessment findings would the nurse correlate with this disorder?

-moon face -petechiae -muscle atrophy

A nurse is caring for a client who develops malignant hyperthermia. Which of the follow actions should the nurse take?

-place cooling blanket on the client -provide 100% oxygen -administer IV dantrolene -infuse iced IV fluids

A nurse is providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make?

-take your heart medication with a sip of water before surgery -splint the abdominal incision with a pillow when coughing and deep breathing -anti-embolism stockings are applied before surgery

One of the functions of nursing care of the terminally ill is to support the client and their family as they come to terms with the diagnosis and progression of the disease process. How should nurses support client and their families during that process?

-try to appreciate and understand the illness from the patients perspective -assist patients with performing a life review -provide interventions that facilitate end-of-life closure

A nurse is caring for a client who manifests indications of hypovolemia while in the PACU. Which of the following findings requires action by the nurse?

-urine output less than 25 mL/hr -tenting of skin over the sternum -BUN 24 mg/dL -hematocrit 53%

A nurse is verifying informed consent for a client who is having paracentesis. Which of the following actions should the nurse take?

-witness the client signing the informed consent form -ensure the client understands information about the procedure -determine if the client is capable of understanding the reason for this procedure

A postoperative patient is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the patient?

-you shouldn't drive while you are taking the medication -check all over-the-counter medications for acetaminophen -eat a diet that is high in fiber and drink lots of water -do not take more pills each day that you are prescribed

A postoperative patient vomited. After cleaning and comforting the patient, which action by the nurse is most important?

auscultate lung sounds

A patient is in stage 2 of general anesthesia. What action by the nurse is most important?

being prepared to suction the airway

A nurse care for a patient with diabetes mellitus who asks, "Why do I need to administer more that one injection of insulin each day?" How would the nurse respond?

a single dose of insulin each day would not match your blood insulin levels and your food intake patterns

A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects?

adrenocortical insufficiency

The nurse is a pediatric ICU is caring for a child who is dying of sickle cell disease. The child's mother has been unable to eat or sleep and can talk only about her impending loss and the guilt she feels about the child's pain and suffering. What intervention has the highest priority?

allowing the mother to express her feeling w/out judgement

A nurse cares for a patient newly diagnosed with Graves' disease. The patient's mother asks, "I have diabetes mellitus. Am I responsible for my daughter's disease?" How does the nurse respond?

an association has been noted between Graves' disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves' disease

A nurse is caring for a client who reports nausea and vomiting 2 days postop following hysterectomy. Which of the following actions should the nurse perform first?

assess bowel sounds

A nurse is assisting an anesthesiologist who is delivering nitrous oxide by face mask to a client during the induction of anesthesia. Which of the following is the priority nursing action?

assess oxygen saturation

The nurse in the surgery clinic is discussing an upcoming surgical procedure with a patient. Which information provided by the nurse is most appropriate for the patient's long-term outcome?

discuss acceptable pain control after your operation with the surgeon

A nurse plans care for a patient who has hypothyroidism and is admitted for pneumonia. Which priority intervention does the nurse include in this patient's plan of care?

ensure that working suction equipment is in the room

A nurse working with older adults in the community plans programming to improve morale and emotional health is this population. What activity would best meet this goal?

exercise program to improve physical function

A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes mellitus?

fasting blood glucose 155 mg/dL

A nurse administered midazolam IV bolus to a client before a procedure. The client's blood pressure is 84/40 mm Hg, and the heart rate is 134/min. Which of the following IV medications should the nurse administer?

flumazenil

A nurse is caring for a client who type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following?

graham crackers

A nurse is caring for a patient on an epidural patient-controlled analgesia (PCA) pump. Which action by the nurse is most important to ensure patient safety?

have another nurse double-check the pump settings

An elderly client has come in to the clinic for her twice-yearly physical. The client tells the nurse that she is generally enjoyed good health, but that she has been having occasional episodes of constipation over the past 6 months. What intervention should the nurse first suggest?

increase daily intake of water

An emergency department nurse assesses a patient with ketoacidosis. Which clinical manifestation would the nurse correlate with this condition?

increased rate and depth of respiration

A nurse assesses a patient who takes lithium. Which assessment finding should alert the nurse to a side effect of this therapy?

increased thirst and urination

The client asks the nurse, "When will the Durable Power of Attorney for Health Care take effect?" On which scientific rationale would the nurse base the response?

it becomes valid only when the clients cannot make their own decisions

The nurse who is a member of the palliative care team is assessing a client. The client indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with his client?

medication should be taken when pain levels are low so the pain is easier to reduce

The nurse is caring for a client who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the client's death is imminent?

mottling of the lower limbs

The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse?

notify me right away if the client's systolic blood pressure is 170 or greater

A nurse works on the postoperative floor and has four patients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the healthcare team for postdischarge care?

older adult who lives at home despite some memory loss

A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate?

oliguria

A student nurse asks why several patients are getting more than one type of pain medication instead of very high doses of one medication. Which response by the registered nurse is best?

pain is so complex it takes different approaches to control it

A patient has arrived in the postoperative unit. What action by the circulating nurse take priority?

participating in hand-off report

A nurse caring for an older patient on a medical-surgical unit notices the patient reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first?

perform an oral assessment

A nurse answers a call light on the postoperative nursing unit. The patient states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action does the nurse take first?

perform hand hygiene and apply gloves

A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first?

place the client in a lateral position

A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take?

place the head of the bed flat

A nurse is caring for a client who develops a systemic toxic reaction following a regional block. Which of the following actions should the nurse take?

provide airway support

The nurse is caring for a client who has just been told that her ovarian cancer is terminal and that no curative options remain. What would be the priority nursing care for this client at this time?

provide emotional support to the patient and her family

a nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?

regular insulin

A circulating nurse wishes to provide emotional support to a patient who was just transferred to the operating room. What action by the nurse would be best?

remain with the patient

A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take?

remove nail polish on fingers and toes

Based on a client's vague explanations for recurring injuries, the nurse suspects that a community-dwelling older adult may be the victim of abuse. What is the nurse's primary responsibility?

report the findings to adult protective services

A medical nurse is providing end-of-life care for a client with metastatic bone cancer. The nurse notes that the client has been receiving oral analgesics for her pain with adequate effect but is now having difficulty swallowing the medication. What should the nurse do?

request the physician to order analgesics by an alternative route

An older adult client has returned to the community following knee replacement surgery. The community health nurse recognizes that the client has prescriptions for nine different medications for the treatment of varied health problems. In addition, she has experienced occasional episodes of dizziness and lightheadedness since her discharge. The nurse should identify which of the following nursing diagnoses?

risk for falls related to polypharmacy and impaired balance

The nurse is admitting a client into hospice care. The client has a diagnosis of Parkinson disease which is progressing rapidly. The client has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care?

supporting the patient's and family's values and choices

After teaching a patient with diabetes mellitus to inject insulin, the nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional teaching?

the lower abdomen is the best location because it is closest to the pancreas

An adult oncology client has a diagnosis of bladder cancer with metastasis and the client has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting?

the patient and family should be viewed as a single unit of care

The home health nurse is making an initial home visit to an older adult client who is a widower. The client takes multiple medications for the treatment of varied chronic health problems. The client states that he has also begun taking some herbal remedies. What should the nurse be sure to include in the client's teaching?

there is a need to inform his physician and pharmacist about the herbal remedies

A postoperative patient has an abdominal drain. What assessment by the nurse indicates that goals for the priority patient problems related to the drain are being met?

there is no redness, warmth, or drainage at the insertion site

A nurse is calling the on-call physician about a patient who has a hysterectomy 2 days ago and his pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication?

this client has allergies to morphine and codeine

A client has just been told that her illness is terminal. The client tearfully states, "I can't believe I am going to die. Why me?" What is the nurse's best response?

this must be very difficult for you

A client's rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this client's care, the nurse should identify what primary aim?

to prevent and relieve suffering

A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

wash your hands before touching the drain or dressing

The nurse is assessing a patient's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. Which question by the nurse would be best to ask the patient for completing a comprehensive pain assessment?

what pain rating would be acceptable to you

The nurse has observed that an older adult client with a diagnosis of end-stage kidney disease seems to prefer to have his eldest some make all of his health care decisions. While the family is visiting, the client explains that this is a cultural practice and very important to him. How should the nurse best respond?

work with the team to negotiate informed consent

A nurse cares for a patient with diabetes mellitus who is visually impaired. The patient asks, "Can I ask my niece to prefill my syringes and then store them for later use when I need them?" How would the nurse respond?

yes, prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up

A nurse is teaching a patient with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL?" How would the nurse respond?

your brain needs a constant supply of glucose because it cannot store it