Exam 1 260 infection, influenza, conjuntivitis, otitis media, pneumonia, TB
The nurse is providing care for a client diagnosed with TB. After learning that a chest x-ray has been ordered, the client asks, "Why do I need another test? They already know what is wrong with me." Which rationale is the nurse's best response?
"An x-ray evaluates the diagnosis and effectiveness of treatment."
A nurse is caring for a client with inflammatory bowel disease and is planning for the most appropriate client interventions. Which nursing diagnosis best supports the interventions needed for the client with inflammatory bowel disease?
-Constipation -Diarrhea -Risk for deficient fluid volume
The infection control nurse is teaching a group of nursing home residents about preventing the spread of infection. The group is not fully familiar with transmission by direct contact. What are ways that pathogens can be spread by direct contact?
-Contact with food -Contact that is person to person -Contact with water -Contact with body fluids
You review Mr. Reeses concurrent disease processes and determine which nursing interventions are a priority to initiate?
-Continually observe cardiac monitor -Review your knowledge of nephrotoxic drugs -Measure hourly intake and output -Auscultate lung sounds during and after fluid boluses
The nurse is caring for a client experiencing manifestations of acute pancreatitis. Which diagnostic tests will assist in confirming this diagnosis?
-Contrast-enhanced CT scan -Magnetic resonance cholangiopancreatography MRCP -Ultrasound
The nurse is providing care to a client diagnosed with chronic renal failure. Which assessment findings are consistent with uremia?
-Crystals noted on the client's skin -Client complaints of pruritus
The nurse is caring for an infant who is scheduled for surgery for pyloric stenosis. When planning the infant's care, which nursing diagnoses are appropriate?
-Deficient Fluid Volume related to inadequate intake and vomiting -Parental Anxiety related to surgery -Sleep Pattern Disturbance related to discomfort and hunger
A nurse is caring for a client diagnosed with intractable nausea and vomiting. What independent nursing interventions help to maintain fluid and electrolytebalance?
-Discussing the need to avoid foods that produce nausea -Teaching the client to restrict fluid intake for 1 hour before and after meals -Teaching the client to seek additional medical help is unable to take in fluids
The nurse is caring for a client diagnosed with septic shock. Which neurological assessment findings require immediate nursing interventions?
-Disorientation -Restlessness -Lethargy
The community health nurse is giving a presentation to a group of new mothers about infant wellness promotion. When teaching about factors that increase an infant's risk for developing otitis media, which items are most appropriate for the nurse to include in the presentation?
-Down syndrome -Enlarged adenoids -Pacifier use -Allergic rhinitis
A client is admitted with cholecystitis and is scheduled for surgery in the morning. The client asks about risk factors for developing cholecystitis. Which risk factors for developing cholecystitis would the nurse indicate to the client?
-Ethnicity -Family history of gallstones -Hyperlipidemia -Obesity
Based on client history, what are the most likely causes?
-Potential lack of access to water secondary to weakness of dominant left hand -Documentation absent for free water administration per gastric tube -Decreased thirst mechanism secondary to age-related changes of the hypothalamus
The nurse is completing a health history on a client admitted in acute renal failure. Which information should the nurse collect? (Select all that apply.)
-Previous transfusion reactions -Recent exposure to nephrotoxic medications -Reports of anorexia -Chronic diseases
A nurse is caring for a client with nephritis and wishes to assist the client in maintaining nutritional balance. Which interventions best support the client's nutritional balance?
-Provide a diet with no added salt -Provide a diet low in protein -Provide opportunity for family to bring food from home
A client with acute cholecystitis is experiencing nausea and vomiting. Which nursing actions address this client's nutritional status?
-Reviewing serum electrolytes -Administering antiemetics per order -Assessing height and weight -Counseling regarding low-fat menu choices
Mr. Benson has improved and is now demonstrating characteristics associated with the convalescent phase of hepatitis B (HBV). Which manifestations are indicative of this phase?
-Sense of well-being -Disappearance of jaundice -Pain free
A client with severe cellulitis is starting intravenous antibiotic treatment. The nurse is explaining situations that should be reported to the healthcare provider. What situation should the nurse described?
-Temperature over 38.3 C (101 F) -Spread of the infected area in the next 24-48 hours -Increased lethargy
The nurse is preparing a plan of care for a client diagnosed with TB. Which goals and outcomes are appropriate to include for this client?
-The client will demonstrate behaviors that reduce the risk of spreading the disease to others -The client will have the resources necessary to obtain required supplies and medications -The client will articulate required treatment and follow-up care
The nurse is providing care to several clients on a medical-surgical unit. Which clients would require priority assessment for the development of septic shock?
-The client with an indwelling urinary catheter -The client admitted with chronic renal failure -The client being treated for an STI -The client admitted for a non healing surgical wound
After reviewing the health history, the nurse suspects that a 4-week-old infant is at risk for developing pyloric stenosis. What did the nurse learn from the client's history to come to thisconclusion?
-The infant is a male -The infant's father had the disorder
The nurse is planning care for a client with ulcerative colitis. Which characteristics associated with ulcerative colitis will the nurse recognize?
-The onset is usually insidious -Attacks last 1 to 3 months -Mild to moderate symptoms are present
The nurse in a community clinic is asked to determine which clients require TB testing. Which individuals should the nurse recommend for this screening?
-Those who are infected with HIV or at high risk for HIV infection -Those who are residents or staff of long term-residential facilities -Those with close contacts who have or are suspected to have TB
You are awaiting the arrival of Mr. Reese's health care provider to re-examine him and write admission orders to the telemetry unit. As you review his lab results, which values indicate Mr. Reese is dehydrated?
-Urine specific gravity 1.030 -Serum sodium 153 mEq/L -Hematocrit 49%
The nurse is reviewing the intake and output (I&O) records of a client. Which entry in the intake record would cause the nurseconcern? (Select all that apply.)
-Vomitus -Tube drainage
A client with bacterial conjunctivitis is experiencing copious amounts of purulent eye drainage. Which treatment should the nurse expect to be prescribed for this client?
-Warm clean cloths -Eye irrigations -Antibiotic eye drops -Eyelid soaks
The nurse is preparing instructions for a client diagnosed with viral conjunctivitis. What should the nurse include in this teaching?
-Wash hands after touching the eyes -Use a wet cloth to remove eye drainage -Avoid bright lights -Apply cool compresses
The nurse is providing instruction to the client with cellulitis on home care measures to increase comfort. What techniques would the nurse provide?
-Wash hands thoroughly before touching the affected area -Get enough rest -Apply sterile saline dressings to the affected area to promote drainage
A 5-year-old client arrives at the community health clinic exhibiting signs of a urinary tract infection (UTI), including fever of 101ºF, strong-smelling urine, and irritability. A urine culture and sensitivity have been ordered. Which causative agent does the nurse expect, based on this diagnostic test?
A gram-negative enteric bacterium
The nurse, caring for an 11-year-old child recovering from an appendectomy, is preparing to help the family ambulate the child for the first time after surgery. Which non-pharmacological nursing strategies would be appropriate for this child?
A splint pillow against the abdomen when moving or coughing
The nurse is caring for a child recovering from surgery for a perforated appendix. Which nursing diagnosis should the nurse use to guide this client's care during the immediate postoperative period?
Risk for infection
A community health nurse is planning to teach a group of clients about the etiology, risk factors, and prevention of nephritis. Which group of clients would best benefit from this education?
-Clients with diabetes -Clients with congestive heart failure -Parents of children with sickle cell disease
While caring for a client recovering from an appendectomy, the nurse monitors urine output, intravenous fluid intake, and the amount of nasogastric drainage. Which nursing diagnosis is the nurse using to guide this client's care?
Risk of deficient fluid volume
After a cursory examination, the health care team suspects that Mr. Benson is suffering some type of hepatitis. Which statements made by Mr. Benson lead you to believe that he has hepatitis B (HBV).
-"I have been sexually active, often with multiple partners, and I don't usually wear a condom." -"I used to share needles with other people when I was using drugs."
The receiving nurse confides that she is unsure how to assess Mr. Reese for continuing signs of hypernatremia and asks if you can help. Which clinical manifestations will you tell her indicate hypernatremia?
-Confusion, possible seizures -Lethargy and weakness -Muscle twitching
The nurse is preparing client education to address the problem of readiness for enhanced knowledge. Which client statement indicates understanding of how to manage acute renal failure after discharge?
-"I will monitor my blood pressure." -"I will avoid life stressors." -"I must monitor for symptoms of possible relapse." -"I need to continue with dietary restrictions."
The nurse is providing education to a junior in college who is studying abroad for the summer. What subject should the nurse include in the instructions regarding hepatitis B?
Safe sexual practice
A client telephones the health clinic with complaints of vague abdominal pain. The client has not been able to eat for a day and is nauseated. What advice should the nurse provide to this client?
Seek immediate medical attention
You want to establish rapport with Mr. Vann to let him know you are available to talk about death. Which statements might help you begin a dialogue with Mr. Vann?
-"I would like to know more about your thoughts on dying." -"Would you like to talk about what's happening to you?"
A nurse is providing care to an infant who underwent a laparoscopic pyloromyotomy. After providing discharge instructions to the infant's care givers, which statements indicate appropriate understanding?
-"It is important to slide the diaper under my baby when changing the diaper." -"I will burp my baby every 1-2 ounces during feedings."
The mother of a 3-year-old child newly diagnosed with an allergy says that she has the same allergy as the child but the child seems to have worse symptoms. What should the nurse explain to the mother?
"Children have more chemicals that encourage inflammation."
A nurse is providing discharge orders for a client with peptic ulcer disease (PUD). What statement will the nurse include regarding client diet and lifestyle modifications for the prevention of PUD?
"Do not skip any meals."
A 2-year-old child with otitis media is prescribed amoxicillin clavulanate 250mg/5 mL three times daily by mouth for 10 days. What should the nurse teach the mother about this medication?
"Give the antibiotic for the full 10 days as prescribed."
"I've been reading about hepatitis on the internet," said Mr. Benson. "I'm confused about all the types of hepatitis. There's hepatitis A, B, C, D, E, and G. Seems like alphabet soup to me. Why all the letters?" How would you respond?
"Hepatitis is caused by at least 7 different viruses, each designated by letters of the alphabet."
Mr. Benson asks you, "What is hepatitis?" What is your best response?
"Hepatitis is the inflammation of the liver tissues; it disrupts the liver's metabolic functions and the elimination of bilirubin."
The nurse is evaluating teaching provided to a client with chronic inflammation. Which client statement indicates that teaching has been successful?
"I limit doing things that aggravate the pain."
A client was admitted with complaints of an elevated temperature,, nausea, and pain and tenderness in the lower right quadrant of the abdomen. After receiving pain medication, the client continues to complain of pain at a level of 8 of 10 on the pain scale. Pain medications are not due for at least another 2 hours. What should the nurse say?
"I will inform the physician about your continued pain."
The nurse is providing home care instruction to the client with cellulitis. Which statement, if made by the client, would concern the nurse the most?
"I will take my antibiotics until the affected area looks less red."
A community health nurse is providing teaching to a group of adults on the prevention of digestive disorders. Which statement will the nurse include in theteaching?
"Immunizations help prevent Hepatitis A."
The nurse is preparing to provide newly prescribed anti-inflammatory medication to a 33-year-old female client with systemic lupus erythematosus. What should the nurse ask this client before providing the medication?
"Is it possible that you are pregnant?"
The nurse is caring for a client who is receiving multiple drugs for treatment of tuberculosis. The nurse teaches the client the rationale for the multiple-drug treatment and evaluates learning as effective when the client makes which statement?
"Multiple drugs are necessary because of the risk of resistance."
The mother of a 10-year-old client is pleased to hear that the child's blood work for inflammation was negative but asks why the child continues to have symptoms. Which response by the nurse is the most appropriate?
"Normal results are common in children with inflammation."
The student health center nurse is talking to a college student who had symptoms of a urinary tract infection (UTI). The student bought over-the-counter Pyridium and no longer has symptoms. The student feels "cured." What is the nurse's best response?
"Pyridium is an analgesic, so it helps the pain, but it does not treat the infection. An antibiotic is needed."
An older client with a ruptured appendix and peritonitis wants to know why the abdomen is swollen. Which explanation by the nurse is the most appropriate?
"The contents of the appendix are causing inflammation of the abdominal cavity."
A client receiving peritoneal dialysis asks the nurse how it works. What is thenurse's best response?
"The fluid that infuses into your abdomen will pull fluid and toxins from the bloodstream, and then the waste products will drain from your abdomen."
A nurse is caring for a client with peptic ulcer disease (PUD). The client tells the nurse, "I don't understand why I have pain in the middle of the night. It's like my pain starts 2-3 hours after I eat, not right away. Why does this happen?" What is the nurse's best response?
"The pain occurs when your stomach is empty."
An occupational health nurse is screening a new employee in a long-term care facility for tuberculosis. The employee questions why purified protein derivative (PPD) testing is done twice. Which is the most appropriate response by the nurse?
"There is an increased risk for false-negative response for people who work in long-term care facilities. The two-step is recommended to accurately screen for TB."
A nurse is caring for an adult client who has a vitamin deficiency. The client asks the nurse why it's important to have adequate vitamin levels in the body. Which response by the nurse is the most appropriate?
"Vitamins support normal growth, maintenance, and repair."
The nurse is performing a nursing assessment on a client who is diagnosed with pneumonia. Which question is important for the nurse to include in the physical examination part of the nursing assessment?
"What is your full name?"
A client with end-stage renal disease (ESRD) tells the nurse, "I feel like half a person. How can I go out in public looking like this?" What is the nurse's best response?
"You seem to be upset about the changes that have occurred in your body as a result of your disease."
You are preparing written discharge information for Mr. Benson. Which statements will youinclude?
-"Follow up with your health care provider for abdominal pain, nausea, and vomiting." -"Check with your health care provider before taking over-the-count medications." -"Rest, adequate nutrition, proper diet, and avoidance of alcohol are essential during the convalescent phase."
The nurse is teaching a client about the long-term complications of diabetes and hypertension. The nurse knows that additional teaching is required when the client makes which statements? (Select all that apply.)
-"My doctor told me the only thing I need to worry about with my high blood pressure is a heart attack or stroke." -"I don't need to worry about my kidneys because diabetes is about sugar in the blood."
The public health nurse is training a novice nurse on tuberculin skin testing. Which information about the test should the public health nurse include in the training?
-"This test is less accurate than the PPD test." -"A multiple-puncture device is used to introduce tuberculin into the skin." -"Vesicular reaction is positive."
A nurse is caring for an infant post-surgery for pyloric stenosis. Which nursing interventions are appropriate when providing care for this infant?
-Administer analgesics, per order -Encourage swaddling and rocking to facilitate relaxation -Instruct the parents on proper diapering to avoid pressure over the incision
The nurse educator is teaching a class about pharmacologic agents that are used in the prevention and treatment of otitis media in children. Which statements are most appropriate for the nurse educator to include in the teaching?
-Amoxicillin is the drug of choice for treatment of pediatric otitis media -Topical anesthetic ear drops may be prescribed -Vaccines may help reduce the risk for developing otitis media
The nurse preceptor is teaching the nursing student about the plan of care for the adult client who is experiencing acute otitis media. Which class of medication is most appropriate for the nurse preceptor to include when teaching about pharmacologic agents that are commonly included in the place of care of the adult client with otitis media?
-Analgesics -Antipyretics -Antibiotics -Antihistamines
A client is admitted for cholelithiasis. The client is not a surgical candidate at this time. Which pharmacologic treatments can be used for this client with cholelithiasis?
-Antibiotics -Ursodiol -Chenodiol -Cholestyramine
The chest x-ray shows consolidation in the right lower lung lobe highly suggestive of pneumonia. You have been unable to obtain a urine specimen; the health care provider begins writing a list of orders. Prioritize the following orders in the sequence in which you will complete them. Instructions: Use the dropdown menus in the left column, to select the correct category for each statement in the right column.
-Apply 100% oxygen by non rebreather mask -Start a cardiac monitor -Begin IV of 0.9% saline -Insert a Foley catheter -Send urine specimen to lab -Administer piperacillin/tazobactam (Zosyn) 3.375 grams IV piggyback every 6 hours
The nurse is providing instruction to the client with diabetes on prevention of cellulitis. What teachings would the nurse provide?
-Apply topical antibiotic to wound daily -Wear properly fitting shoes -Wash would carefully with soap and water
The nurse in the emergency department is caring for a client with a temperature of 102.5 F, productive cough, chills, shortness of breath and malaise. Which diagnostic tests does the nurse expect to have ordered for this client?
-Arterial blood gas -Chest x-ray -Sputum culture and sensitivity
The nurse is caring for an infant who is admitted for possible pyloric stenosis. When assessing the infant, which actions are appropriate?
-Auscultate bowel sounds -Palpate the right upper quadrant of the abdomen -Observe the infant's abdomen
The nurse is providing education to a group of volunteers who are planting trees in a city park on a hot, sunny day. What teaching should the nurse provide about avoiding heat-related illness? (Select all that apply.)
-Avoid participating int he tree planting if ill -Wear lightweight clothes -Take frequent rest breaks
The nurse is caring for a client with hepatitis. Which treatments are considered supportive?
-Avoiding alcohol -Proper diet -Rest
The infection control nurse is talking about the history of the H1N1 influenza. The nurse points out that the virus had genes from more than one source. What sources contributed to the H1N1 virus?
-Bird genes -Human genes -Genes from flu viruses found in pigs
A client diagnosed with acute renal failure is experiencing hyperkalemia. Which medication should the nurse anticipate being prescribed to this client?
-Calcium chloride -Insulin -Sodium bicarbonate -Glucose
The nurse is evaluating a client recovering at home after an emergency appendectomy. Which observations indicate thatself-care has been effective?
-Client plans to recover at home until cleared by the surgeon -Client uses a pillow to splint incision before coughing -Client performs abdominal wound care appropriately
A middle-aged obese woman presents with right upper quadrant abdominal pain present for the past several hours. The nurse suspects that the client is at risk for the formation of gallstones. Which risk factors will the nurse assess this client for during the health history?
-Excess cholesterol -Inflammation of the gallbladder -Abnormal bile composition -Biliary stasis
The nurse caring for a homeless client at risk for tuberculosis will include which symptoms of the disease when educating the client?
-Fatigue -Weight loss -Night sweats
The charge nurse for a medical-surgical unit is notified that a client with tuberculosis (TB) is being transported to the unit. Which actions for infection prevention are the most appropriate in this circumstance?
-Have the client wear a mask when coming from admissions -Wear a mask and gown when caring for the client -Test all staff members for TB immediately
The nurse is providing education to a new nurse about renal failure. Which condition causes damage to the renal parenchyma and nephrons?
-Hemolysis -Hypertension -Glomerulonephritis -Vasculitis
The nurse obtaining an adult client's history of past events to assess current risk for infection. What facts should be included?
-History of recurrent infections -History of family tendency for certain infections -History of immunizations
The clinic nurse wants to document the stage in the infectious process of a client with a same-day appointment. Which symptoms would lead the nurse to record that the client was in the illness stage?
-Impaired function -Pain
Which clinical manifestation indicates Mr. Reese is tolerating the gastric tube feedings?
-Improvement in chest x-ray -Diarrhea
The nurse is providing care to an infant who underwent surgery for pyloric stenosis. Which actions by the nurse will decrease the risk for infection when caring for this infant?
-Inspect the incision for redness, swelling, or discharge -Auscultate the lungs to assess for any adventitious sounds
Which nutritional modifications are therapeutic for clients experiencing an episode of cholecystitis?
-Limiting food intake -Nasogastric tube insertion -Low-fat diet
The nurse is caring for a client with pneumonia administers a variety of classifications of pharmacologic therapies in collaboration with the healthcare team. Which medications may be appropriate for a client with pneumonia?
-Liquefying agents -Bronchodilators -Oxygen therapies -Broad spectrum antibodies
A client is brought to the emergency department following a motor vehicle crash. What diagnostic tests should you anticipate the healthcare provider ordering to help determine risk for shock?
-MRI -CT scan -Gastric tonometry
The nurse is monitoring a client who has undergone a thyroidectomy. The nurse suspects the parathyroid glands may have been inadvertently removed if imbalances are seen in which serum electrolyte level? (Select all that apply.)
-Magnesium -Calcium
The nurse is educating a client about complications associated with chronic pancreatitis. Which potential complications would the nurse include in this education?
-Malnutrition -Diabetes mellitus -Peptic ulcer disease -Opioid addiction
A nurse is caring for a client with tuberculosis who is taking Rifampin for treatment of the disease. Of which nursing considerations should the nurse be aware regarding this medication?
-Monitor CBC, liver function studies, and renal function studies for evidence of toxicity -Administer on an empty stomach
A nurse assigned to the intensive care unit for a client diagnosed with septic shock. Which nursing interventions should the nurse include the client's plan of care to anticipate complications of shock?
-Monitor fluid status with intake and output -Assess the client's mental status -Monitor client's blood pressure and pulse
Which nursing actions are appropriate to reduce the risk of infection for a hospitalized client recovering from a laparoscopic cholecystectomy?
-Monitoring vital signs, including temperature, every 4 hours -Assessing abdomen every 4 hours as indicated post surgery -Assisting client to deep breathe and cough or use incentive spirometers every 1 to 2 hours while awake -Administering antibiotics as prescribed
A middle-aged client wants to know about the choices of over-the-counter drugs for treating flu symptoms. Which nonprescription drugs can the nurse suggest?
-Non-steroidal anti-inflammatory drugs -Acetaminophen -Aspirin
List the pathophysiology processes involved in appendicitis in sequential order.
-Obstruction of the proximal lumen of the appendix is apparent -The appendix becomes distended with fluid secreted by its mucosa -Pressure within the lumen of the appendix increases -Purulent exudate formed causes further distention of the appendix -Tissue necrosis and gangrene result
The nurse is caring for a client in the Emergency Department who is suspected of having appendicitis. What should the nurse expect to be prescribed for this client?
-Pain medication -Complete white blood cell count -A cephalosporin
A 1-month-old infant with projectile vomiting is brought into the clinic. Which clinical manifestations would make the nurse suspect pyloric stenosis?
-Persistent hunger -Blood-tinged vomit -Peristaltic wave
With the assistance of a sign language interpreter, the clinic nurse is interviewing a deaf client to complete the flu risk health history. The client is coughing and febrile. Which questions are necessary to assess for flu risk?
-What is the client's history of influenza vaccinations? -How long has the client had flu symptoms? -What is the client's known exposure to the flu virus?
As the nurse caring for Mr. Benson, you anticipate the health care provider will order which diagnostic tests to confirm the diagnosis of hepatitis B (HBV)?
Serum bilirubin, alaine aminotransferase ALT, and aspartate aminotransferase AST
Mr. Vann's temperature is 97.2° F. His pulse and respiratory rates are WNL. You decide to check if he has postural hypotension. In what order will you take the steps necessary to assess that vital sign?
1-Ask Mr. Vann to lie down on his bed for 10 minutes 2-Record his pulse and blood pressure 3-Assist Mr. Vann to slowly sit on the side of his bed or stand next to it 4-Immediately recheck his pulse and blood pressure 5-Repeat the measurements after 3 minutes 6-Record the results
As the nurse, you are considering the pathophysiological changes occurring with Mr.Benson's disease condition. What is the sequence of events related to the condition of hepatitis?
1-The liver is infected with a virus 2-The acini cells develop mononuclear inflammatory infiltrates 3-Edema within the liver obstructs the biliary canal 4-Obstructive jaundice develops and liver cell begin necrosis
Mr. Benson is wondering how long he could have been infected with hepatitis B. As his nurse, you recognize that the incubation period for hepatitis B (HBV) is what time frame?
2-6 months
Mr. Bagwell is started on temazepam (Restoril), 7.5 mg at bedtime for one week, and then increasing to 12.5 mg for one week; at the end of the second week he is to return to the clinic. Temazepam comes in 5 mg tablets. How many tablets will you instruct Mr. Bagwell to take the second week of therapy? Please limit your answer to a numeral. Record your answer to one decimal place.
2.5
A two-week-old infant with pyloric stenosis is prescribed intravenous fluid with potassium chloride. What should the nurse expect to be prescribed for the infant after the infusion has been provided?
Serum potassium level
A nurse manager is teaching a group of staff nurses about the complications related to peptic ulcer disease (PUD). What statement regarding peritonitis will the nurse manager include in the teaching?
Peritonitis occurs when the ulcer penetrates through the mucosal wall, causing gastric or duodenal contents to enter the peritoneum
The nurse is caring for a 35-year-old male client who is complaining of left ear pain. When using an otoscope to examine the client's left ear, which action is most appropriate for the nurse to implement?
Selecting a speculum with the largest diameter that will fit comfortably in the client's ear
The nurse is scheduling diagnostic tests prescribed for a 4-week-old infant who is suspected of having pyloric stenosis. Which diagnostic test should the nurse schedule to be completed first?
Abdominal ultrasound
A nurse is caring for a client with a suspected bowel obstruction. What diagnostic test will aid in confirming this diagnosis?
Abdominal x-ray
The results of an abdominal ultrasound were inconclusive for a client experiencing vague right lower quadrant abdominal pain. Which diagnostic test will the nurse prepare the client for at this time?
Abdominal x-rays
A client presents to the emergency department with symptoms of right upper-quadrant pain,fatigue, nausea, and vomiting. Laboratory work is completed and indicates that the client is in acute liver failure. What are the causes of acute liver failure?
Acetaminophen overdose
A new mother is distraught because her infant has a fever of 102 F and diagnosed with otitis media. What should the nurse instruct the mother to help the child's fever and pain?
Administer acetaminophen
The nurse is teaching the parents of an infant with acute otitis media. What would be most important for the nurse to teach the parents?
Administer acetaminophen to relieve pain and decrease fever
The nurse knows that preserving renal perfusion is important in the care of a client with chronic renal disease. Which intervention supports this principle?
Administering an angiotensin-converting enzyme inhibitor per orders
The residents and staff of a nursing home are in a geographical area with reports of confirmed influenza cases. The nurse administrator has decided to offer antiviral medication to all staff and residents as a preventive measure. When is it safe for them to stop taking the drugs?
After 7 days with no new flu cases
A nurse is caring for a client with Goodpasture syndrome who recently had plasmapheresis for treatment of this condition. The nurse notes petechiae and bruising to the client's abdomen and face. Which potential complication of plasmapheresis does the nurse suspect?
Alteration of coagulation
The client asks the nurse, "How did I get this urinary tract infection (UTI)?" The nurse bases the response on which common causative factor?
An ascending infection from the urethra
A nurse is caring for a client with congestive heart failure (CHF) who has recently been diagnosed with peptic ulcer disease (PUD). The client takes digoxin to manage symptoms associated with CHF. The healthcare provider has ordered antacids for the client to help heal the gastric mucosa as a result of PUD. What is true regarding antacids and digoxin?
Antacids interfere with the absorption of digoxin
The public health nurse is completing a community assessment regarding the increased incidence of TB. Which population in the community should the nurse identify as having the greatest risk for contracting and developing TB?
Asian Immigrants
The nurse is caring for a client, admitted with severe malnutrition, who required the insertion for a gastrostomy tube. The nurse bases the client's care on the understanding that the client is at risk for developing which type of pneumonia?
Aspiration pneumonia
A client with appendicitis is highly agitated and states that there is a great deal of pain. Which intervention will decrease the client's anxiety?
Assess pain levels every 2 hours and administer ordered medication
The nurse is reviewing the medication record of a client admitted with dehydration. Which medication would cause the nurse concern?
Benzodiazepine
As the admitting nurse, you assess if Mr. Benson works in an occupation that may predispose him to hepatitis. Which of the following occupations places the patient at greatest risk for hepatitis B infection?
Blood bank technician
The nurse notes that a client is prescribed a dietary consult as part of treatment for inflammation. What should the nurse expect to assess in this client?
Body mass index 42
A client is brought to the emergency department for treatment of possibly sepsis. Which pharmacologic therapy is a priority for this client?
Broad-spectrum antibiotics
The school nurse is talking to fifth grader about the use of tissues when blowing one's nose. Which causes of a runny nose should the nurse include in the teaching session?
Cells that line the breathing passages dying and releasing fluid
A nurse is planning care for a client with inflammatory bowel disease. What goal or outcome is the best choice for this client?
Client recognized the early signs of a flare up
The nurse is evaluating teaching provided to an adolescent on the treatment for conjunctivitis. Which observation indicated that additional teaching is required?
Client uses the back of the hand to remove eye drainage
The nurse understands that there are several ways that pneumonia is classified. Which type of pneumonia does the nurse suspect in a client who is not a resident of a long-term care facility and is diagnosed within 48 hours of admission to the hospital?
Community-acquired pneumonia
The nurse is providing discharge instructions for a client with pneumonia. What information is essential for the nurse to include?
Complete the prescribed medication regimen
During a home visit, the nurse realizes that teaching provided to the parents of a school-age child with conjunctivitis was not effective. What did the nurse observe to come to this conclusion?
Conjunctivitis diagnosed in the child's other eye
The nurse practitioner is caring for a 3-year-old client who is experiencing otitis media. The client's mother asks the nurse practitioner, "Why aren't you giving my child a prescription for an antibiotics?" Which response by the nurse practitioner is most appropriate?
Conservative antibiotic administration when treating otitis media helps reduce antibiotic resistance
A client with acute abdominal pain is scheduled for an appendectomy in 3 hours. While waiting for the surgery, the client reports that the pain has subsided. What should the nurse do?
Contact the physician
A client comes into the emergency department (ED) experiencing blurred vision, severe pain, and watery drainage from the left eye. Which eye problem should the nurse suspect is occurring with this client?
Corneal abrasion
The nurse is preparing to assess a 90-year-old client admitted with tuberculosis. Which manifestation will the nurse most likely assess in this client?
Cough
During an assessment, the nurse becomes concerned that a client is experiencing early signs of acute appendicitis. Which assessment finding causes this concern?
Right lower quadrant abdominal pain aggravated by coughing
A nurse is planning care for a client who is going to be admitted to the nurse's unit. The client has a diagnosis of peptic ulcer disease (PUD) and is complaining of nausea, heartburn, and epigastric pain. What nursing intervention will the nurse plan to implement?
Discourage the client from eating a nighttime snack
A client presents to the healthcare provider's office with cellulitis on the lower leg. Other than the inflammation of the leg, the client has no other symptoms. The nurse anticipates an order for which test to determine the causative organism?
Drainage culture
The nurse is providing discharge education to a client diagnosed with hepatitis. What information should the nurse include for dealing with daily fatigue?
Encourage planned rest periods during the day
After a week of caring for a client with the flu, the home care nurse modifies a nursing intervention concerning fluids; adds a new nursing diagnosis and intervention related to ineffective airway clearance; and discontinued a nursing diagnosis of fatigue. Which phase of the nursing process does this activity represent?
Evaluation
The 25-year-old female is visiting family from Iran and develops signs and symptoms of appendicitis during the night. The client is brought to the Emergency Department by the family. Which nursing intervention is the most culturally sensitive for this client?
Explain the assessment procedure and ask the family their preference
A client with acute pancreatitis has a positive Turner sign. Where would the nurse assess the client to identify this positive sign?
Flank area
The nurse is monitoring the fluid and electrolyte status of a client receiving intravenous colloids. The nurse understands that it is priority to monitor the client for manifestations of which imbalance?
Fluid overload
The client was surprised when the nurse performing an assessment of risk for infection asked about family history of infections. Which characteristics of heredity would affect the current generation's risk of infections?
Having a genetic susceptibility to certain infections
The nurse is reviewing laboratory values for a client with hyperthyroidism. Which component of the complete blood count will be most useful to the nurse in determining the client's fluid status?
Hematocrit
A client is newly diagnosed with acute pancreatitis. What medication will the nurse administer to assist in controlling the client's pain?
Hydromorphone (Dilaudid)
A nurse is unable to secure an intravenous access site due to severe dehydration. Which order does the nurse anticipate receiving from the healthcare provider?
Hypodermoclysis
After the first 1000 mL of 0.9% saline is infused, what type of IV fluids did you expect the health care provider to order next based on Mr. Reese's lab values?
Hypotonic
As the nurse caring for Mr. Benson, you continually assess his symptoms to determine which phase of hepatitis he is currently experiencing. This morning, 3 days after his admission, Mr. Benson appears jaundiced. You suspect he is in what stage of hepatitis?
Icteric phase
The nurse is visiting the home of an infant recovering from surgery to correct pyloric stenosis. Which observation should the nurse immediately report to the healthcare provider?
Incisional site is dark red and edematous
The nurse is preparing to educate a client diagnosed with acute renal failure about dietary needs. Which information should the nurse include?
Increase carbohydrates
You also note the same diffuse accessory muscle use observed at the care center. Which assessment parameter(s) indicate a need to notify the health care provider to see this client as a priority?
Increasing respiratory rate, decreasing SpO2
The nurse is planning care for a 90-year-old client who was recently diagnosed with tuberculosis. The client lives alone in an apartment and will continue treatment at home. Which nursing diagnosis is a priority for this client?
Ineffective Therapeutic Regimen Management
The nurse is caring for an older adult client diagnosed with nephritis and congestive heart failure(CHF). Which clinical finding may be present in this client, which is not a typical finding in the client withnephritis?
Infiltrates on chest x-ray
The nurse is caring for a hospitalized client who is experiencing anxiety-related hyperventilation. To account for the client's hyperventilation, when recording the client's fluid intake and output, the nurse should adjust the amount of fluid lost through which route?
Insensible loss
The nurse is caring for a client with chronic pancreatitis. Which finding would the nurse expect during the client's pain assessment?
Intermittent pain to mid abdomen and mid back
While reviewing laboratory results, the nurse notes that one client has an elevated C-reactive protein level. What should the nurse identify as a priority for this client?
Interventions to rule out the diagnosis of liver failure
The nurse is caring for a client who has been admitted to the unit with tuberculosis. The client is placed in isolation. To protect the caregivers and other clients on the unit, which type of isolation room is most appropriate?
Isolation room with an anteroom and negative air flow (Air flows into the room)
The nurse is providing care to a client with TB. The client is a heavy drinker, and liver enzyme tests reveal damage. Which medication prescription should the nurse question for this client?
Isoniazid (NH)
The public health nurse is training a class on first aid methods. The nurse talks about the activity of pathogens in each stage of the infectious process, including one that could last for years. What are pathogens doing during this stage?
Pathogens replicate, but do not cause manifestations
A client is newly diagnosed with acute postinfectious glomerulonephritis. Which medication will the nurse administer to manage the protein loss associated with nephrotic syndrome?
Lisinopril (Zestril)
A nurse is caring for a client with nephritis who also has ascites due to excess fluid volume. Which action by the nurse is the best way to monitor the client's degree of ascites?
Measure abdominal girth
A nurse conducting an assessment interview about risk for infections asks the client, "On a scale of 1 to 10, how would you rate the stress you have experienced in the last 6 months?" Why is the nurse including that question in the interview?
Measuring client's severity of emotional stressors
A client with newly diagnosed otitis media tells the nurse that the left ear has been aching for weeks. Since this health problem has been untreated for so long, which additional problem is this client at risk for developing?
Meningitis
The nurse is monitoring a 2-year-old client with cellulitis that developed from an insect bite on the face. The nurse understands that what is a complication that can develop from facial cellulitis?
Meningitis
The client asks the nurse, "What factors increase my risk for developing barotitis media?" Which response by the nurse is most appropriate?
Narrowed eustachian tubes
The nurse walks into the examination room and sees a young child demonstrate a specific behavior. Which health problem should the nurse suspect the child is experiencing?
Otitis Media
During a home visit, the nurse instructs a young mother to bottle-feed the baby in the upright position. Which infectious health problem will this position help to prevent this child from developing?
Otitis media
A client has completed the full course of antibiotics prescribed to treat otitis media. Which primary manifestation of the disorder will be relieved as evidence that treatment has been effective?
Pain
An adolescent client is brought to the emergency department (ED) with fatigue, weight loss, a dry cough, and night sweats. The family just recently immigrated to the United States. Based on this data, for which potential risk should the nurse include when planning care for this client?
Pneumothorax
The nurse is caring for a client in acute renal failure resulting from an obstruction due to cancer. Which type of acute renal failure is the client experiencing?
Postrenal
You found that Mr. Vann's pulse rose from 60 to 80 beats per minute and his systolic blood pressure dropped from 110 to 90 mmHg as he went from lying down to sitting up in his chair again. What condition did you confirm, and what is its cause?
Postural hypotension caused by dehydration
The parent of a child with repeated urinary tract infections (UTIs) is worried because her child has not been progressing like other children of the same age. Which nursing diagnosis would be the most appropriate for this client?
Potential for growth retardation
While eating a peanut butter sandwich as a bedtime snack, the nurse observes a client begin to wheeze and complain of dizziness. What should the nurse do first?
Prepare to administer epinephrine
Before they leave, Mrs. Bagwell asks you if there are any complementary or alternative therapies to help her husband sleep. Which practice will you discuss with the Bagwells?
Progressive relaxation
The nurse is caring for a client in the emergency department (ED) who has been diagnosed with a urinary tract infection(UTI) and is complaining of pain. The nurse teaches the client to expect which medication for the treatment of pain?
Pyridium
The nurse is assessing the 1-year-old for signs and symptoms that may be associated with acute otitis media. Which assessment finding is most reflective of a potential manifestation of acute otitis media in the pediatric client?
Rapid onset of symptoms
A nurse inserts a nasogastric feeding tube for a client with dysphagia. Once the tube is in place, the client begins to retch and complains of nausea. What is the priority action by the nurse in response to the client's manifestations?
Reassess placement of the tube
The nurse is planning care for a client in the early stages of ulcerative colitis. The nurse understands that which part of the colon is initially affected by ulcerative colitis?
Rectosigmoid area
The nurse is preparing teaching materials for the parents of a 7-year-old child newly diagnosed with a severe allergy to dust. What should the nurse include in this teaching?
Remove stuffed toys from home
An adolescent with otitis media is experiencing extreme pain. Which should the nurse emphasize to address the diagnosis of Acute Pain for this client?
Report abrupt relief of pain immediately
During a home visit, the nurse identifies conjunctivitis in both eyes of a 14-day-old infant. What additional information does the nurse need to determine the cause of this infant's eye infection?
Results of mother's testing for sexually transmitted infections
As you watch the health care provider write the admission orders, which order will require further clarification?
Resume medications via gastric tube as per schedule at care center
The nurse is evaluating the teaching provided to the mother of an infant recovering from surgery to correct pyloric stenosis. Which observation indicates that the teaching has beeneffective?
Slides the diaper under the infant's buttock
A nurse is caring for a client diagnosed with a urinary tract infection. When providing education to this client, which topic should not be included as a bladder irritant?
Smoking
The nurse is caring for a client who has been diagnosed with late-stage chronic pancreatitis. Which client symptom most supports this diagnosis?
Steatorrhea
Visitors to a hospitalized client discover a poster about "universal precautions" outside the client's room. They ask the nurse providing care about the meaning of that phrase. Which explanation can the nurse give them?
Techniques used with all clients to decrease risk of infection
The nurse is assessing a client with chronic hepatitis who is receiving lamivudine (Epivir). Which assessment finding is a priority to communicate to the healthcare provider?
The client has become lethargic and is hyperventilating
A nurse is planning care for a client with peptic ulcer disease (PUD) who presents with intractable nausea and vomiting and epigastric pain. What is an appropriate outcome for this client?
The client will maintain adequate fluid volume
A nurse is caring for a client with hepatitis, cirrhosis, and pernicious anemia. What do these conditions have in common?
They are all alterations of gastric absorption
The nurse is providing care to a client with chronic renal failure. The nurse reads in the medical record that the client is a Jehovah's Witness. The client is scheduled to receive a kidney transplant in several weeks. Which action does the nurse expect from this client?
To adhere to the beliefs of Jehovah's Witnesses regarding blood transfusions
The nurse is admitting a client with ulcerative colitis who is scheduled for surgery. The client tells the nurse that he is having his bowel removed and will have a temporary ostomy for 2 to 3 months. Which upcoming surgical procedure is the client describing?
Total colectomy ileal pouch-anl anastomosis IPAA
The nurse in an inner city clinic is providing a health screening for a homeless man with a history of drug abuse. The client has a chronic non-productive cough. For what should the nurse expect to screen this client?
Tuberculosis
The nurse is caring for a client admitted for abdominal pain and jaundice. The nurse suspects a diagnosis of hepatitis. The client recently traveled outside the United States. Which type of hepatitis does the nurse suspect?
Type A
A client is brought to the emergency department for treatment of possible toxic shock syndrome. Which manifestation should the nurse anticipate when assessing this client?
Vomiting
During a visit to the home of a new mother, the nurse becomes concerned that the infant has pyloric stenosis. Which manifestation did the nurse note in the infant?
Vomiting 30 minutes after a feeding
The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus. Which action is most appropriate by the nurse?
Withholding food and fluid intake until intestinal motility has returned
A new mother brings a male infant, 2-weeks-old, to the pediatric clinic for a check-up. The mother is concerned that her infant may be at risk for pyloric stenosis due to her age and because her husband had surgery for the condition when he was an infant. Which responses by the nurse are the most appropriate based on this data?
Your baby has a greater risk for the condition due to a familial history
