Exam 3

A nurse is assessing a client who s dehydrated. Which of the following findings should the nurse expect? a. Moist skin b. Distended neck veins c. Increased urinary output d. Tachycardia

A nurse is assessing a client who s dehydrated. Which of the following findings should the nurse expect? a. Moist skin b. Distended neck veins c. Increased urinary output d. Tachycardia

A nurse is caring for a client who has a new diagnosis of TB and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol? a. Your urine can turn a dark orange b. Watch for a change in the sclera of your eyes c. Watch for any changes in vision d. Take vitamin B6 daily

Watch for any changes in vision

A nurse is preparing to administer a new prescription for isoniazid to a light skinned client who has TB. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? a. You might notice yellowing of your skin b. You might experience pain in your joints c. You might notice tingling of your hands d. You might experience a loss of appetite

You might notice tingling of your hands

A nurse is teaching a client who has TB. Which of the following statements should the nurse include? a. You will need to continue to take the multi-medication regimen for 4 months b. You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication c. You will need to remain hospitalized for treatment d. You will need to wear a mask at all times

You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication

Which of these client's is/are most likely to develop fluid overload? Select all that apply a. A premature infant b. A 101-year-old man c. A client with heart failure d. A client with diabetes mellitus e. A client receiving renal dialysis f. A 29-year-old client with pneumonia

a. A premature infant b. A 101-year-old man c. A client with heart failure e. A client receiving renal dialysis

The nurse is preparing a list of homecare instructions for the client who has been hospitalized and treated for TB. Which instructions would the nurse reinforce? Select all that apply a. Activities need to be resumed gradually b. Avoid contact with other individuals except family members for at least 6 months c. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated d. Respiratory isolation is not necessary because family members have already been exposed e. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags f. When one sputum culture is negative, the client is no longer considered infectious and can usually return to his or her former employment

a. Activities need to be resumed gradually c. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated d. Respiratory isolation is not necessary because family members have already been exposed e. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags

A nurse is preparing educational material to present to a female client who has frequent UTI infections. Which of the following information should the nurse include? Select all that apply a. Avoid sitting in a wet bathing suit b. Wipe the perineal area back to from following elimination c. Empty the bladder when there is an urge to void d. Wear synthetic fabric underwear e. Take a shower daily

a. Avoid sitting in a wet bathing suit c. Empty the bladder when there is an urge to void e. Take a shower daily

The nurse is preparing an IV solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse would plan to take which action? a. Change the IV tubing b. Wipe the tubing with betadine c. Scrub the tubing with an alcohol swab d. Scrub the tubing before attaching it to the IV bag

a. Change the IV tubing

A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? Select all that apply a. Client who has dysphagia b. Client who has AIDS c. Client who was vaccinated for pneumococcus and influenza 6 months ago d. Client who is postop and has received local anesthesia e. Client who has a closed head injury and is receiving mechanical ventilation f. Client who has myasthenia gravis

a. Client who has dysphagia b. Client who has AIDS e. Client who has a closed head injury and is receiving mechanical ventilation f. Client who has myasthenia gravis

A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes and blood pressure 102/64 mm Hg. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? Select all that apply a. Decreased skin turgor b. Concentrated urine c. Bradycardia d. Low grade fever e. Tachypnea

a. Decreased skin turgor b. Concentrated urine d. Low grade fever e. Tachypnea

A nurse is planning care for a client who has a small bowel obstruction and a NG tube in place. Which of the following interventions should the nurse include? Select all that apply a. Document the NG drainage with the client's output b. Irrigate the NG tube every 8 hours c. Assess bowel sounds d. Provide oral hygiene every 2 hours e. Monitor NG tube for placement

a. Document the NG drainage with the client's output c. Assess bowel sounds d. Provide oral hygiene every 2 hours e. Monitor NG tube for placement

A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5lbs) in 48 hours. Which of the following manifestations of fluid volume excess should the nurse expect? Select all that apply a. Dyspnea b. Edema c. Bradycardia d. Hypertension e. Weakness

a. Dyspnea b. Edema d. Hypertension e. Weakness

A nurse is caring for a client who has a blood potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations? a. ECG changes b. Constipation c. Polyuria d. Paresthesia

a. ECG changes (this is the only option for hyperkalemia. The others are for hypokalemia)

A nurse is caring for a client who has a small bowel obstruction from adhesions. Which of the following findings are consistent with this diagnosis? Select all that apply a. Emesis greater than 500 mL with a fecal odor b. Report of spasmodic abdominal pain c. High pitched bowel sounds d. Abdomen flat with rebound tenderness to palpation e. Laboratory findings indicating metabolic acidosis

a. Emesis greater than 500 mL with a fecal odor b. Report of spasmodic abdominal pain c. High pitched bowel sounds

A nurse is discussing risk factors for urinary tract infections with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? Select all that apply a. Epidural anesthesia b. Urinary bladder catheterization c. Frequent pelvic exams d. History of UTIs e. Vaginal birth

a. Epidural anesthesia b. Urinary bladder catheterization c. Frequent pelvic exams d. History of UTIs

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the IV site of an assigned client who is receiving fluid replacement therapy how often? a. Every hour b. Every 2 hours c. Every 3 hours d. Every 4 hours

a. Every hour

A nurse is reviewing a client's medication history notes an allergy to sulfonamides. This allergy is a contraindication for taking with of the following medications? Select all that apply a. Hydrochlorothiazide b. Metoprolol c. Acetaminophen d. Glipizide e. Furosemide

a. Hydrochlorothiazide d. Glipizide e. Furosemide

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? a. I should wash my hands after blowing my nose to prevent spreading the virus b. I need to avoid drinking fluids if I develop symptoms c. I need a flu shot every 2 years because of the different flu strains d. I should cover my mouth with my hand when I sneeze

a. I should wash my hands after blowing my nose to prevent spreading the virus

The nurse has provided instructions to the mother of an infant with viral pneumonia. Which statement by the mother would indicate the need for further teaching? a. I understand I will need to have my baby on antibiotics for this pneumonia. b. I will need to give a cough suppressant before meals if his cough gets too bad c. I will be careful and allow my baby to sleep so he can conserve energy and fight this infection d. I understand that my baby has viral pneumonia and I need to monitor his temperature because of the risk for febrile seizures

a. I understand I will need to have my baby on antibiotics for this pneumonia.

A nurse is reviewing discharge instructions with a client who had spontaneous passage of a calcium phosphate renal calculus. Which of the following instructions should the nurse include in the teaching? Select all that apply a. Limit intake of food high in animal protein b. Reduce sodium intake c. Strain urine for 48 hours d. Report burning with urination to the provider e. Increase fluid intake to 3 liters a day

a. Limit intake of food high in animal protein b. Reduce sodium intake d. Report burning with urination to the provider e. Increase fluid intake to 3 liters a day

A nurse is teaching a client who has a new prescription for nitrofurantoin. Which of the following information should the nurse include? Select all that apply a. Observe for bruising on the skin b. Take the medication with milk or meals c. Expect brown discoloration of urine d. Crush the medication if it is difficult to swallow e. Expect insomnia when taking it

a. Observe for bruising on the skin b. Take the medication with milk or meals c. Expect brown discoloration of urine

A nurse is teaching a client who has a severe UTI about ciprofloxacin. Which of the following information about adverse reactions should the nurse include? Select all that apply a. Observe for pain and swelling of the Achilles tendon b. Watch for a vaginal yeast infection c. Expect excessive nighttime perspiration d. Inspect the mouth for cottage cheese like lesions e. Take the medication with a dairy product

a. Observe for pain and swelling of the Achilles tendon b. Watch for a vaginal yeast infection d. Inspect the mouth for cottage cheese like lesions

The nurse is checking the insertion site of a peripheral IV catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is most likely the result of which complication? a. Phlebitis of the vein b. Infiltration of the IV line c. Hypersensitivity to the IV solution d. An allergic reaction to the IV catheter material

a. Phlebitis of the vein

A nurse in a provider's office is instructing a guardian of a toddler how to administer ear drops. Which of the following instructions should the nurse include? Select all that apply a. Place the child on the unaffected side when you are ready to administer the medication b. Warm the medication by gently rolling it between your hands for a few minutes c. Gently shake medication that is in suspension form d. Keep the child on their side for 5 minutes after instillation of the ear drops e. Tightly pack the ear with cotton after instillation of the ear drops

a. Place the child on the unaffected side when you are ready to administer the medication b. Warm the medication by gently rolling it between your hands for a few minutes c. Gently shake medication that is in suspension form d. Keep the child on their side for 5 minutes after instillation of the ear drops

The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique? a. Pullin the pinna up and back b. Pulling the earlobe down and back c. Tilting the client's head forward and down d. Instructing the client to stand and lean to one side

a. Pullin the pinna up and back

.The nurse notes that a hospitalized client has experienced a positive reaction to the TB skin test. Which action by the nurse is the priority? a. Report the findings b. Document the findings in the client's record c. Call the employee health service department d. Call the radiology department for a chest x-ray

a. Report the findings

A nurse is caring for a client who has a blood sodium level 133 mEq/L and blood potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these lab findings? a. Three tap water enemas b. NS IV at 50 mL/hr c. D5 1/2NS with 20K IV at 80 mL/hr d. Antibiotic therapy

a. Three tap water enemas

The nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would take which actions while changing the client's hospital gown? Select all that apply a. Using a hospital gown with snaps at the sleeves b. Disconnecting the IV tubing from the catheter in the vein c. Checking the IV flow rate immediately after changing the hospital gown d. Putting the bag and tubing through the sleeve, followed by the client's arm e. Cutting the sleeves of the hospital gown and using safety pins to hold the sleeves together

a. Using a hospital gown with snaps at the sleeves c. Checking the IV flow rate immediately after changing the hospital gown d. Putting the bag and tubing through the sleeve, followed by the client's arm

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? a. Vitals b. Skin color c. Oxygen saturation d. Latest hematocrit level

a. Vitals (change can indicate a reaction. Vitals are checked before the procedure, every 15 minutes for the first half hour after beginning the transfusion, and every half hour thereafter)

A client is going to be transfused with a unit of packed red blood cells. The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? a. 5 minutes b. 15 minutes c. 30 minutes d. 45 minutes

b. 15 minutes

A nurse is caring for an infant who has manifestations of acute otitis media. Which of the following factors places the infant at risk for otitis media? Select all that apply a. Breastfeeds without formula supplementation b. Attends day care 4 days per week c. Immunizations are up to date d. History of a cleft palate repair e. Parents smoke cigarettes outside

b. Attends day care 4 days per week d. History of a cleft palate repair e. Parents smoke cigarettes outside

A nurse is teaching a parent of a child who has a UTI. Which of the following should the nurse include in the teaching? Select all that apply a. Wear nylon underpants b. Avoid bubble baths c. Empty bladder completely with each void d. Watch for manifestations of infection e. Wipe perineal area back to front

b. Avoid bubble baths c. Empty bladder completely with each void d. Watch for manifestations of infection

An 18-month-old child is being discharged after surgical repair of hypospadias. Which postop nursing care measure would the nurse stress to the parents as they prepare to take this child home? a. Leave diapers off to allow the site to heal b. Avoid tub baths until the stent has been removed c. Encourage toilet training to ensure that the flow of urine is normal d. Restrict the fluid intake to reduce urinary output for the first few days

b. Avoid tub baths until the stent has been removed

A nurse is completing discharge instructions with a client who has spontaneously passed a calcium oxalate calculus. To decrease the change of recurrence, the nurse should instruct the client to avoid which of the following foods? a. Red meat b. Black tea c. Cheese d. Whole grains e. Spinach

b. Black tea e. Spinach

A client with BPH undergoes a transurethral resection of the prostate and is receiving continuous bladder irrigations postop. Which are the signs/symptoms of transurethral resection syndrome? a. Tachycardia and diarrhea b. Bradycardia and confusion c. Increased urinary output and anemia d. Decreased urinary output and bladder spams

b. Bradycardia and confusion

The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells. The nurse would tell the client that it is most important to report which sings immediately? a. Sore throat or earache b. Chills, itching, or rash c. Unusual sleepiness or fatigue d. Mild discomfort at the catheter site

b. Chills, itching, or rash

A nurse is completing the admission assessment of a client who has renal calculi. Which of the following findings should the nurse expect? a. Bradycardia b. Diaphoresis c. Nocturia d. Bradypnea

b. Diaphoresis

A nurse is caring for a child who has enuresis. Which of the following is a complication of enuresis? a. UTI b. Emotional problems c. Urosepsis d. Progressive kidney disease

b. Emotional problems

A nurse is caring for a client who has a NG tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? a. Hypercalcemia b. Hyponatremia c. Hyperphosphatemia d. Hyperkalemia

b. Hyponatremia

A nurse is assessing an infant who has a suspected UTI. Which of the following are expected findings? Select all that apply a. Increase in hunger b. Irritability c. Decrease in urination d. Vomiting e. Fever

b. Irritability d. Vomiting e. Fever

A nurse is reviewing urinalysis results for four clients. Which of the following urinalysis results indicated a UTI? a. Positive for hyaline casts b. Positive for leukocyte esterase c. Positive for ketones d. Positive for crystals

b. Positive for leukocyte esterase

A nurse is assessing an infant. Which of the following findings are clinical manifestations of acute otitis media? Select all that apply a. Decreased pain in the supine position b. Rolling head side to side c. Loss of appetite d. Increased sensitivity to sound e. Crying

b. Rolling head side to side c. Loss of appetite e. Crying

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? a. Inflammation b. Serous drainage c. Pain at a pin site d. Purulent drainage

b. Serous drainage

A nurse is assessing a child who has a UTI. Which of the following are manifestations of a UTI? Select all that apply a. Night sweats b. Swelling of the face c. Pallor d. Pale colored urine e. Fatigue

b. Swelling of the face c. Pallor e. Fatigue

A nurse is assessing a client in an extended care facility. The nurse should recognize which of the following findings is a manifestation of an obstruction of the large intestine due to a fecal impaction? a. The client reports one bowel movement yesterday b. The client is having small, frequent liquid stools c. The client is flatulent d. The client indicates vomiting once this morning

b. The client is having small, frequent liquid stools

A nurse is completing an admission assessment for a client who has a small bowel obstruction. Which of the following findings should the nurse report to the provider? Select all that apply a. Emesis prior to insertion of the NG tube b. Urine specific gravity 1.040 c. Hematocrit 60% d. Blood potassium 3.0 mEq/L e. WBC 10,000/uL

b. Urine specific gravity 1.040 (range is 1.005 to 1.030. An increase can mean dehydration) c. Hematocrit 60% (range is 37%-52%. An increase can mean dehydration) d. Blood potassium 3.0 mEq/L

A nurse is caring for a toddler who has had rhinitis, cough, and diarrhea for 2 days. Upon assessment, it is noted that the tympanic membrane has an orange discoloration and decreased movement. Which of the following statements should the nurse to make? a. Your child has an ear infection that requires antibiotics b. Your child could experience transient hearing loss c. Your child will need to be on a decongestant until this clears d. Your child will need to have a myringotomy

b. Your child could experience transient hearing loss

The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a TB infection? a. An uninsured man who is homeless b. A woman newly immigrated from another country c. A man who is an inspector for the postal service d. An older woman admitted from a long-term care facility

c. A man who is an inspector for the postal service

A nurse is caring for a client who has a left renal calculus and an indwelling urinary catheter. Which of the following assessment findings is the priority for the nurse to report to the provider? a. Flank pain that radiates to the lower abdomen b. Client report of nausea c. Absent urine output for 1 hour d. Blood WBC count 15,000/mm3

c. Absent urine output for 1 hour

The nurse is monitoring an older client suspected of having a UTI for signs of infection. Which sign/symptom is likely to present first? a. Fever b. Urgency c. Confusion d. Frequency

c. Confusion

A client has epididymitis as a complication of a UTI. The nurse is giving the client instructions to prevent recurrence. The nurse determines that the client needs further teaching if the client states the intention to take which action? a. Drink an increased amount of fluids b. Limit the force of stream during voiding c. Continue to take antibiotics until all symptoms are gone d. Use condoms to eliminate risk associated with chlamydia and gonorrhea

c. Continue to take antibiotics until all symptoms are gone

A nurse is providing information about TB to a group of clients at a local community center. Which of the following manifestations should the nurse include? Select all that apply a. Persistent cough b. Weight gain c. Fatigue d. Night sweats e. Purulent sputum

c. Fatigue d. Night sweats e. Purulent sputum

A parent with a 6-year-old child diagnosed with enuresis discusses with the nurse the measures that are being taken to help her child. Which statement by the parent indicates a need for further teaching? a. I make sure that my child goes potty before going to bed b. I will praise my child and think of a reward for him staying dry c. I take away privileges such as TV time when the bed is wet in the morning d. I make sure that my child does not have anything to drink 2 hours before bedtime

c. I take away privileges such as TV time when the bed is wet in the morning

A nurse is reviewing discharge teaching with a client who has a UTI. Which of the following statements by the client indicates understanding of the teaching? Select all that apply a. I will perform perineal care and apply a perineal pad in a back to front direction b. I will drink grape juice to make my urine more acidic c. I will drink large amounts of fluids to flush the bacteria from my urinary tract d. I will go back to breastfeeding after I have finished taking the antibiotic e. I will take Tylenol for any discomfort

c. I will drink large amounts of fluids to flush the bacteria from my urinary tract e. I will take Tylenol for any discomfort

The nurse is doing a routine assessment of a client's peripheral IV site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which complication has probably occurred? a. Phlebitis b. Infection c. Infiltration d. Thrombosis

c. Infiltration

The nurse is checking the casted extremity of a client. The nurse needs to check for which sign indicative of infection? a. Dependent edema b. Diminished distal pulse c. Presence of a "hot spot" on the cast d. Coolness and pallor of the extremity

c. Presence of a "hot spot" on the cast

The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child with otitis media. Which would be included in the plan? a. War gloves when administering the eardrops b. Pull the ear up and back before instilling the ear drops c. Pull the earlobe down and back before instilling the eardrops d. Hold the child in a sitting position when administering the eardrops

c. Pull the earlobe down and back before instilling the eardrops

A nurse is caring for a toddler who has had three ear infections in the past 5 months. Which of the following long-term complications is the child at risk for developing? a. Balance difficulties b. Rash c. Speech delays d. Mastoiditis

c. Speech delays

The nurse is gathering data on a client with a diagnosis of TB. The nurse would review the results of which diagnostic test to confirm this diagnosis? a. Chest x-ray b. Bronchoscopy c. Sputum culture d. TB skin test

c. Sputum culture

A nurse is planning discharge teaching for a female client who has a new prescription for trimethoprim-sulfamethoxazole. Which of the following information should the nurse include? a. Take the medication even if pregnant b. Maintain a fluid restriction while taking it c. Take it on an empty stomach d. Stop taking it when manifestations subside

c. Take it on an empty stomach

A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? a. Apply a blood pressure cuff to the client's arm b. Place the stethoscope bell over the client's carotid artery c. Tap lightly on the client's cheek d. Ask the client to lower their chin to their chest

c. Tap lightly on the client's cheek

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? a. The pharmacy b. The lab c. The blood bank d. The risk management department

c. The blood bank

The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? a. An increased hematocrit level b. An increased hemoglobin level c. A decline of the temperature to normal d. A decrease in oozing from puncture sites and gums

d. A decrease in oozing from puncture sites and gums

A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority action for the nurse to take? a. Provide emotional support to the family b. Educate the family on care of the child c. Provide a diversional activity d. Administer analgesics

d. Administer analgesics

A client has a prescription to receive 1000 mL of D5 ½ NS. After gathering the appropriate equipment, the nurse takes which action first before spiking the bag with the tubing? a. Uncap the distal end of the tubing b. Uncap the spike portion of the tubing c. Opens the roller clamp on the IV tubing d. Closes the roller clamp on the IV tubing

d. Closes the roller clamp on the IV tubing

The nurse is collecting data from a client who has had BPH in the past. To determine whether the client is currently experiencing exacerbation of BPH, the nurse would ask the client about the presence of which early symptom? a. Nocturia b. Urinary retention c. Urge incontinence d. Decreased force in the stream of urine

d. Decreased force in the stream of urine

The nurse has been instructed to remove an IV line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item? a. Band aid b. Alcohol swab c. Betadine swab d. Gauze

d. Gauze

The nurse is reinforcing discharge teaching to a client diagnosed with TB who has been taking medication for a week and a half. The nurse knows that the client has understood the information if which statement is made? a. I can't shop at the mall for the next 6 months b. I need to continue medication therapy for 2 months c. I can return to work if a sputum culture comes back negative d. I should not be contagious after 2 to 3 weeks of medication therapy

d. I should not be contagious after 2 to 3 weeks of medication therapy

The nurse is reviewing instructions to a parent of a 6-year-old on how to prevent influenza. Which statement by the parent indicates a need for further teaching? a. I will get a flu shot and I will have my child get a flu shot too b. I will avoid having my child come into contact with sick children c. I will have my child wash her hands frequently during the flu season d. I will not let my child play with other children who have the flu unless they are taking acetaminophen

d. I will not let my child play with other children who have the flu unless they are taking acetaminophen

A nurse is caring for a client in a long term care facility who has become weak, confused, and experienced dizziness when standing. The client's temperature is 38.3*C (100.9*F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. Which of the following actions should the nurse take? a. Initiate fluid restrictions to limit intake b. Check for peripheral edema c. Encourage the client to ambulate to promote oxygenation d. Monitor for orthostatic hypotension

d. Monitor for orthostatic hypotension

A nurse is teaching a group of guardians about influenza. Which of the following information should the nurse include in the teaching? a. Amantadine will prevent the illness b. Rimantadine is administered intramuscularly c. Zanamivir can be given to children 1 year and older d. Oseltamivir should be given within 48 hours of onset of manifestations

d. Oseltamivir should be given within 48 hours of onset of manifestations

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100*F orally. The nurse reports the finding to the RN and anticipates that which action will take place? a. The transfusion will begin as prescribed b. The transfusion will begin after the administration of an antihistamine c. The transfusion will begin after the administration of 650 mg of Tylenol d. The blood will be held, and the provider will be notified

d. The blood will be held, and the provider will be notified

A client being discharged from the hospital to home with a diagnosis of TB is worried about the possibility of infecting family members and others. Which information would reassure the client that contaminating family members and others is not likely? a. The family does not need therapy and the client will not be contagious after 1 month of medication therapy b. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy c. The family will receive prophylactic therapy, and the client will not be contagious after 1 continuous week of medication therapy d. The family will receive prophylactic therapy and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy

d. The family will receive prophylactic therapy and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy

A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How would the nurse correctly interpret these findings? a. Bacteremia b. Fluid overload c. Hypovolemic shock d. Transfusion reaction

d. Transfusion reaction

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 100*F, respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions a. Administer antibiotics b. Administer oxygen therapy c. Perform a sputum culture d. Instruct the client to obtain a yearly influenza vaccination

i. Administer oxygen therapy ii. Perform a sputum culture (do this before administering antibiotics so you can get an accurate culture) iii. Administer antibiotics iv. Instruct the client to obtain a yearly influenza vaccination

A home health nurse is teaching a client who has active TB and is following a medication regimen that includes a combination of isoniazid, rifampin, pyrazinamide, and ethambutol. Which of the following client statements indicate an understanding? Select all that apply a. I can substitute one medication for another if I run out because they all fight infection b. I will wash my hands each time I cough c. I will wear a mask when I am in public areas d. I am glad I don't have to have any more sputum specimens e. I don't need to worry where I go once I start taking my medications

I will wash my hands each time I cough I will wear a mask when I am in public areas

The client who has a cold is seen in the ER with an inability to void. Because the client has a history of BPH, the nurse determines that the client needs to be questioned about the use of which class of medications? a. Diuretics b. Antibiotics c. Antitussives d. Decongestants

d. Decongestants

A nurse is caring for a client who has a UTI. Which of the following is the priority intervention by the nurse? a. Offer a warm sitz bath b. Recommend drinking cranberry juice c. Encourage increased fluids d. Administer antibiotics

d. Administer antibiotics

Isoniazid is prescribed for a 2-year-old child with a positive TB skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother? a. 4 months b. 9 months c. 12 months d. 18 months

9 months

A nurse is planning care of a child who has a UTI. Which of the following interventions should the nurse include? a. Administer an antidiuretic b. Restrict fluid c. Evaluate the child's self esteem d. Encourage frequent voiding

d. Encourage frequent voiding

A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? a. Diabetic ketoacidosis b. Heart failure c. Cushing's syndrome d. Thyroidectomy

a. Diabetic ketoacidosis

The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching? a. I need to wash my hands frequently b. I need to clean the eye as prescribed c. I need to give the eye drops as prescribed d. I need to use hot compresses to relieve the eye irritation

d. I need to use hot compresses to relieve the eye irritation