EXITk 10

Clients who have casts applied to the lower extremities must be monitored for complications. Which finding during assessment of the extremities of these clients is indicative of a complication? Select all that apply.

Numbness Prolonged capillary refill

Which common initial clinical effects should the nurse expect a client with multiple sclerosis to exhibit? Select all that apply.

Nystagmus Scanning speech Intention tremors

A nurse is caring for a client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? Select all that apply.

Obese trunk Sleep disturbance Thin arms and legs

A client who is 60 pounds more than the ideal body weight is admitted to the hospital with a diagnosis of type 1 diabetes. Which concept should the nurse include in teaching about diabetes when discussing strategies to lose weight?

Obesity leads to insulin resistance

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm?

Sudden severe headache

The nurse is caring for a client who has had frequent premature ventricular complexes (PVCs) and monitors the client closely for ventricular fibrillation. The nurse recalls that the risk for ventricular fibrillation is greatest during which phase of the cardiac cycle?

T wave

A client with hyperthyroidism is treated with radioactive iodine to ablate thyroid tissue. What should the nurse instruct the client to do after the procedure?

Avoid holding an infant.

A client has been admitted with severe edema and hypertension. Intravenous furosemide (Lasix) has been prescribed. Which subjective clinical manifestations lead the nurse to suspect that the furosemide is infusing too rapidly? Select all that apply.

Tinnitus Weakness Leg cramps

A health care provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply.

Double vision Difficulty swallowing saliva Drooping of the upper eye lids

Which clinical findings does the nurse anticipate a client with an exacerbation of multiple sclerosis will experience? Select all that apply.

Double vision Scanning speech

The nurse expects the diagnostic studies of a client with Cushing syndrome to indicate:

High levels of 17-ketosteroids in a 24-hour urine test

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply.

Hirsutism Buffalo hump

The nurse provides education related to manifestations of hyperglycemia to a client with type 1 diabetes. Which signs and symptoms identified by the client indicate that the teaching was effective? Select all that apply.

Thirst Fruity breath odor Excessive urination

During rounds, a nurse observes a client who is experiencing a tonic-clonic seizure. Which actions by the nurse are correct? Select all that apply.

Move obstacles away from the client Turn the client to the side

What clinical indicators should the nurse expect when interviewing and assessing a client with Ménière's disease? Select all that apply.

Nausea Dizziness Jerky lateral eye movements

What nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke?

Place objects within the visual field.

During administration of a whole blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize the following nursing actions.

1.)Elevate the head of the bed to 45 degrees 2.) apply oxygen via nasal cannula 3.) reduce flow rate 4.) administer furosemide 5.) document findings

The nurse is completing an assessment on a couple seeking genetic counseling for sickle cell anemia. Both prospective parents carry sickle cell traits. The nurse recognizes that the couple has what chance of having a child who develops the disease?

25%

Building confidence in one's worth is important for a client who is scheduled for a below-the-knee amputation (BKA) because an amputation:

Affects an idealized self-image

A client who had a myocardial infarction is in the coronary care unit on a cardiac monitor. The nurse observes ventricular irritability on the screen. What medication should the nurse prepare to administer?

Amiodarone (Cordarone)

A nurse performs preoperative teaching for a client who is to have cataract surgery. Which is most important for the nurse to include concerning what the client should do after surgery?

Avoid bending from the waist

A client falls from a two-story building and is taken to the hospital unconscious. Which finding identified during the initial nursing assessment should be of most concern?

Bleeding from the ears

Aspirin is prescribed for a client with rheumatoid arthritis. Which clinical indicators of aspirin toxicity should the nurse teach the client to report? Select all that apply.

Blood in the stool Ringing in the ears

What should the nurse include in a teaching plan for a client taking calcium channel blockers such as Nifedipine (Procardia)? Select all that apply.

Change positions slowly. Report peripheral edema. Avoid drinking grapefruit juice.

A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply.

Cool skin Constipation Periorbital edema Decreased appetite

The nurse evaluates that the teaching about myasthenic and cholinergic crises is understood when a client who is diagnosed with myasthenia gravis states that a characteristic common to both crises is:

Difficulty breathing

The nurse is providing care for a client with small-cell carcinoma of the lung that develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What clinical findings correspond with the secretion of antidiuretic hormone (ADH)? Select all that apply.

Edema Hyponatremia

A client complains of foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. The nurse concludes that further teaching is needed when the client states, "I will:

Elevate my foot"

A nurse is preparing to obtain a blood specimen for culture and sensitivity from a client with an elevated temperature for the last two days. Place in order of priority the nursing actions that should be taken.

Explain the procedure to the client Collect the specimen according to protocol. Send the specimen to the laboratory Administer the first dose of antibiotics

A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome?

Glucose level

A nurse is assessing a client with Cushing syndrome. Which signs should the nurse expect the client to exhibit? Select all that apply.

Hirsutism Round face Buffalo hump

The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect the client to experience increased pain and limited movement of the joints?

In the morning on awakening

After a craniotomy to remove a brain tumor, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which clinical indicators should the nurse monitor the client? Select all that apply.

Increased weight Decreased serum sodium Decreased level of consciousness

Which action should the nurse take when caring for a client with malaria?

Provide nutrition between paroxysms.

Dexamethasone (Decadron) has been prescribed for a client after a craniotomy for a brain tumor. When evaluating the effectiveness of the medication, the nurse expects what physiological response?

Reduced cerebral edema

A nurse is assessing the legs of a client with a history of chronic venous insufficiency. What physiologic changes should the nurse conclude are the result of this disease process? Select all that apply.

Stasis ulcer Brown discoloration

What potentially adverse effect of an intravenous titrated drip of lidocaine (Xylocaine) should the nurse immediately report to the healthcare provider?

Tremors

A client with a gastric hemorrhage is to receive 2 units of whole blood. List the nurse's activities in the order that they should be performed when administering a blood transfusion

Verify that typing and crossmatching of the prescribed blood has occurred. Flush the infusion tubing with normal saline. Ask another nurse to check the blood at the client's bedside. Run the blood at a slower rate during the first 10 minutes of the transfusion.

A client signs a legal consent for hip replacement surgery. Shortly before surgery, the client states, "I decided not to go through with the surgery." What is the best initial response by the nurse?

"Let's talk about your concerns regarding the procedure."

A client who is suspected of having leukemia has a bone marrow aspiration. Immediately after the procedure, the nurse should:

Apply brief pressure to the site

A client is scheduled for a below-the-knee amputation. When should the nurse begin rehabilitation planning for the client?

Before the surgery

A client has a decreased serum sodium level. The nurse should assess the client for which signs of hyponatremia? Select all that apply.

Confusion Muscle weakness

After a long leg cast is removed, the nurse should instruct the client to:

Elevate the leg when sitting

A nurse is creating a plan of care for range-of-motion exercises for a client with rheumatoid arthritis who has severe pain and swelling of the joints in both hands. What should the plan include?

Applying heat or cold before the exercises.

When caring for a client who has hyponatremia, the nurse would monitor for which of the following?

Decreased specific gravity

The nurse is caring for a client with Parkinson disease. Which of the following is a priority nursing concern?

risk for injury

A nurse determines that a client exhibits the characteristic gait associated with Parkinson disease. How should the nurse describe this gait when recording on the client's progress report?

shuffling

A client with type 1 diabetes self-administers NPH insulin (Novolin N) every morning at 8:00 AM. The nurse concludes that the client understands the action of this insulin when the client says, "I should be alert for signs of hypoglycemia between:

12 PM and 8 PM."

When caring for a person with myasthenia gravis, a nurse considers the differences between myasthenic and cholinergic crises. The nurse concludes that:

Atropine is used to treat cholinergic crisis

A health care provider in the emergency department identifies that a client is in mild hypovolemic shock. Which type of drug should the nurse anticipate will be prescribed?

3.Sympathomimetic

A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes to painful stimuli, makes incomprehensible sounds, and flexes to pain. Using the Glasgow Coma Scale, what does the nurse determine the client's score is?

7

The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). The nurse expects to find:

A decrease in CD4 T cells

A client weighing 125 kilograms (275 pounds), is considered to be in septic shock when the mean arterial pressure is less than 65 mm Hg or the systolic blood pressure is less than 90 mm Hg after receiving how many liters of intravenous crystalloids?

5 L

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. The Glasgow Coma Scale score that indicates the client is in a coma is a score of:

6

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? Select all that apply.

Absence of hair on the toes Reports of pain associated with exercising

A client has serially decreasing blood pressures after surgery. Which mechanisms involved in the regulation of blood pressure should the nurse consider? Select all that apply.

Activation of regulators that control renal angiotensin II. Increase of left ventricular stroke volume to maintain blood volume. Enervation of the sympathetic nervous system to constrict arterioles.

Immediately after cataract surgery a client complains of feeling nauseated. The nurse should:

Administer the prescribed antiemetic

What should the nurse assess for in the immediate postoperative period after a client has brain surgery?

Decreased level of consciousness

A client has a below-the-knee amputation and asks why the prosthesis is applied immediately after surgery. The nurse informs the client that the primary reason is to:

Encourage a normal walking pattern

What should the nurse do to prevent deformities of the knee in a client with an exacerbation of arthritis? Select all that apply.

Encourage motion of the joint. Maintain joints in functional alignment when resting.

A transfusion of packed red blood cells is prescribed for a client with anemia. List the following actions in the order in which they should be performed by the nurse.

Ensure that the client signed a consent for the transfusion. Determine the client's vital signs Compare the number on the blood product and laboratory record. 4. Don a pair of clean gloves Run the transfusion slowly.

A client with small cell carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH). What signs should the nurse expect to observe? Select all that apply.

Oliguria Seizures Vomiting

A client comes to the outpatient clinic with a large leg ulcer. The clinical finding that supports the diagnosis of arterial ulcer is:

Pain at the ulcer site

A nurse is assessing a client with a diagnosis of hypoglycemia. What clinical manifestations support this diagnosis? Select all that apply.

Palpitations Diaphoresis Slurred speech

The serum potassium level of a client who has diabetic ketoacidosis is 5.4 mEq/L. When monitoring the ECG tracing, the nurse expects to observe:

Peaked T waves and widened QRS complexes

A nurse is caring for a client who just had an above-the-knee amputation. What is the key factor in assessing how the client will cope with the body image change?

Personal perception of the change

The nurse cares for a client who develops pyrexia three days after surgery. The nurse should monitor the client for which signs and symptoms commonly associated with pyrexia? Select all that apply.

Tachypnea Increased pulse rate

A client sustains a fractured right femur in a fall on the ice and is admitted to the hospital's emergency department. How should the nurse assess this client for signs of circulatory impairment?

Take the client's pedal pulse in the affected extremity

A client sustains a fractured right femur after an automobile accident and is admitted to the hospital's emergency department. How will the nurse assess this client for signs of circulatory impairment?

Take the client's pedal pulse in the affected extremity.

A client is scheduled for a computed tomography (CT) of the brain with contrast. Upon review of the client's medical record, what significant finding should the nurse report to the health care provider before the diagnostic procedure? The client:

Takes metformin (Glucophage) daily.

A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. The nurse should suggest:

Taking a hot tub bath or shower in the morning

A client is at risk for increased intracranial pressure (ICP). Which of the following assessment findings reflects an increase in ICP?

Unequal pupil size

A client with osteoarthritis who had a left total hip replacement returns to the unit after surgery. The nurse should place the client in which position?

Use pillows to keep the client's legs abducted

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client?

Use standard precautions.

The nurse is caring for an elderly client who has a right hip fracture. What intervention should be included in the plan of care?

Venous thromboembolism prevention (VTE)

The nurse teaches a group of clients that nutritional support of natural defense mechanisms indicates the need for a diet high in:

Vitamins A, C, E, and selenium

A client is admitted with a diagnosis of Cushing syndrome. For which clinical manifestations should the nurse observe when assessing this client? Select all that apply.

Weakness Hypertension Truncal obesity

A client is diagnosed with herpes genitalis. What should the nurse do to prevent cross-contamination?

Wear a gown and gloves when giving direct care.

A nurse is caring for a client with an underactive thyroid gland. Which responses should the nurse expect the client to exhibit as a result of decreased levels of triiodothyronine (T3) and thyroxine (T4)? Select all that apply.

Weight gain Cold intolerance

What clinical indicators should a nurse expect when assessing a client with hyperthyroidism? Select all that apply.

Weight loss Tachycardia Restlessness Exophthalmos

The client receiving a blood transfusion that was just initiated complains of urticaria and difficulty breathing. The heart rate has increased, the blood pressure is falling, and the client is becoming extremely apprehensive. These are symptoms of which type of shock?

Anaphylactic shock

A client with the diagnosis of Cushing syndrome has the following laboratory results: Na (sodium) 149 mEq/L; K (potassium) 3.2 mEq/L; Hb (hemoglobin) 17 g/dL; and glucose 90 mg/dL. What should the nurse teach the client? Select all that apply.

Avoid foods high in salt. Eat foods high in potassium.

The nurse teaches a client with exophthalmos how to reduce discomfort and prevent corneal ulceration. The nurse concludes that the teaching is understood when the client states, "I should:

Avoid using a sleeping mask at night.

A nurse is caring for a client who is receiving a unit of packed red blood cells. Which findings lead the nurse to suspect a transfusion reaction caused by incompatible blood? Select all that apply.

Backache Shivering

A client who sustained a severe head injury remains unconscious. During the client's assessment, the nurse observes bleeding from the left ear and rhinorrhea. The nurse concludes that drainage from the ear and nose indicates a:

Basilar fracture

A nurse is providing discharge instructions about digoxin (Lanoxin). Which response should a nurse include as a reason for a client to withhold the digoxin?

Blurred vision

The registered nurse determines that the new graduate understands the type(s) of hepatitis that generally develop into a chronic hepatitis infection if the graduate identifies which of the following? Select all that apply

C and D

After undergoing a cardiac catheterization, the client complains of tingling sensations in the affected leg. To determine the cause of the tingling, the nurse should:

Compare femoral, popliteal, and pedal pulses in both legs

A client presents to the emergency department with a fever, headache, loss of appetite, and malaise. The nurse identifies raised red bumps on the client's arms and legs. A diagnosis of chickenpox is made. The client should be placed in a private room with what kind of precautions? Select all that apply.

Contact precautions Airborne precautions

A nurse is assessing a client with a diagnosis of hypothyroidism. Which clinical manifestations should the nurse expect when assessing this client? Select all that apply.

Dry skin Brittle hair

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask what are the symptoms of bleeding for which they should be looking in the future. What are the signs for which to look? Select all that apply.

Epistaxis Hematuria Hemarthrosis Easy bruising Dark colored tarry stool

A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include that will decrease the risk of complications? Select all that apply.

Examining the feet daily Wearing well-fitting shoes Performing regular exercise

The nurse is planning discharge instructions for a client who had a thyroidectomy. For which signs of surgically induced hypothyroidism should the nurse alert the client? Select all that apply.

Fatigue Correct Incorrect 2 Dry skin

A client is diagnosed with hyperthyroidism and is treated with 131I. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms should be included in the teaching? Select all that apply.

Fatigue Dry skin Progressive weight gain

Before a client's discharge after a thyroidectomy, the nurse teaches the client to observe for signs of surgically induced hypothyroidism. What clinical indicators identified by the client provide evidence that the nurse's instructions are understood? Select all that apply.

Fatigue Dry skin

A nurse is caring for a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). The IV infiltrates and needs to be restarted. What is necessary to protect the nurse when restarting the IV? Select all that apply.

Gloves Hand hygiene

A nurse is caring for a newly admitted client with a diagnosis of Cushing syndrome. Why should the nurse monitor this client for clinical indicators of diabetes mellitus?

Glucocorticoids accelerate the process of gluco-neogenesis.

The parents of a young man suspected of having Cushing syndrome expresses anxiety about their son's condition. What should the nurse tell the parents to help them better understand the illness?

He may have mood swings or depression as a result of his illness.

A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the cerebral cortex. The nurse recognizes that, postoperatively, the position that is most appropriate for this client is:

Head of the bed elevated 30 to 45 degrees with the neck in neutral alignment

A client with Addisonian crisis exhibits severe manifestations of glucocorticoid and mineralocorticoid deficiencies. Which responses should the nurse expect the client to exhibit? Select all that apply.

Hyperkalemia Hyponatremia Postural hypotension

A client with a tentative diagnosis of Cushing syndrome has an increased cortisol level. For what response should the nurse assess this client?

Hypernatremia

A client's diet is modified to eliminate foods that act as cardiac stimulants. The nurse should teach the client to avoid what foods? Select all that apply.

Iced tea, Hot cocoa Chocolate pudding

A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor. What intervention is the priority?

Immediate defibrillation

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma?

Impairment of peripheral vision

Pyridostigmine (Mestinon) is prescribed for a client with myasthenia gravis. The primary reason that the nurse instructs the client to take pyridostigmine about one hour before meals is to:

Increase chewing strength

A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis?

Increased blood urea nitrogen levels

A nurse is caring for two clients; one has polycythemia and the other has prolonged anemia. What do these clients have in common?

Increased cardiac workload

During the neurological assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, the nurse expects that the client will manifest:

Increased muscular weakness

A client is found unconscious and unresponsive. What should the nurse do first?

Initiate a code.

When a client develops ventricular fibrillation in a coronary care unit, what is the responsibility of the first person reaching the client?

Initiate defibrillation.

An older adult, who alternately lives in a homeless shelter and on the street, is brought to the emergency department by friends. The client has a fever, night sweats, and a blood-tinged productive cough. The health care provider suspects that the client has tuberculosis and prescribes a purified protein derivate (PPD) test, chest x-ray, and sputum culture. Place these interventions in the order that they should be performed.

Institute airborne precautions. Have a chest x-ray performed Perform a PPD intradermal skin test. Obtain a sputum specimen. Notify the Department of Health.

An older adult, who alternately lives in a homeless shelter and on the street, is brought to the emergency department by friends. The client has a fever, night sweats, and a blood-tinged productive cough. The health care provider suspects that the client has tuberculosis and prescribes a purified protein derivate (PPD) test, chest x-ray, and sputum culture. Place these interventions in the order that they should be performed.

Institute airborne precautions.. Have a chest x-ray performed.. Perform a PPD intradermal skin test. Obtain a sputum specimen. Notify the Department of Health.

A client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. What should the nurse do to prepare the client for the procedure?

Instruct the client to void.

The client is admitted with supraventricular tachycardia at a rate of 140 beats per minute. The client's blood pressure is 110/55 mm Hg, and he is asymptomatic except for a "fluttering feeling" in his chest. Which of the following treatments would be appropriate? Select all that apply:

Intravenous adenosine (Adenocard) Intravenous beta blockers Intravenous calcium channel blockers Intravenous amiodarone

A family member of a client with a hemorrhagic stroke asks about anticoagulant therapy. The nurse explains that anticoagulant therapy for the client:

Is contraindicated because it will increase bleeding. What therapeutic effect does the nurse expect to identify when mannitol (Osmitrol) is administered parenterally to a client with cerebral edema? Decreased intracranial pressure

The nurse is caring for a client diagnosed with Cushing syndrome. The nurse expects that the client will exhibit:

Lability of mood

Which clinical indicators can the nurse expect when assessing a client with Cushing syndrome? Select all that apply.

Lability of mood Slow wound healing

A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? Select all that apply.

Lack of hair Thickened toenails Pain at the ulcer site Diminished pedal pulse

A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? Select all that apply.

Lack of hair thickened toenails pain at the ulcer site diminished pedal pulse

A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane?

Left hand

A nurse is caring for a client who has had type 1 diabetes for 25 years. The client states, "I have been really bad for the last 15 years. I have not paid attention to my diet and have done little to control my diabetes." What signs of common complications of diabetes might the nurse expect to identify when assessing this client? Select all that apply.

Leg ulcers Correct Incorrect 2 Loss of visual acuity Correct Incorrect 3 Thick, yellow toenails Decreased sensation in the feet

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client?

Lethargy

During the progressive stage of shock, anaerobic metabolism occurs. For which complication should the nurse assess the client?

Metabolic acidosis

After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused as to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. Which nursing action takes priority?

Monitoring the client for increasing intracranial pressure.

A client is admitted to the hospital with a diagnosis of Cushing syndrome. When performing an assessment, the nurse should take into consideration that the client will most likely exhibit signs of:

Muscle weakness and frequent urination

A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? Select all that apply.

Nausea and vomiting Increased weight Decreased serum sodium Decreased level of consciousness

A client is suspected of having rabies after being bitten by a raccoon. For which clinical indicators should the nurse assess the client? Select all that apply.

Nuchal rigidity Pharyngeal spasm

An older adult is brought to the emergency department after being found in the street without a coat during a snowstorm. What actions should the nurse implement? Select all that apply.

Obtain a rectal temperature. Assess the fingers for areas of frostbite. Determine client's level of consciousness. Ask for client identification.

A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which clinical indicator is unique to a fat embolus?

Pinpoint red spots on the chest

An older adult who was in a motor vehicle collision is brought to the emergency department via ambulance. The client exhibits a decreased level of consciousness, and the nurse identifies serosanguinous drainage from the client's left ear. What should the nurse do?

Place a sterile pad over the external ear

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours?

Prevent pressure ulcers

After an amputation, a client's residual limb is bandaged snugly throughout the postoperative period. The nurse teaches the client that the primary purpose of the rigid bandaging of the residual limb is to:

Promote shrinkage of the distal end of the residual limb

A nurse mixes a short-acting and an intermediate-acting insulin in the same syringe to administer to a client with diabetes. List the actions in the order the nurse should perform them.

Put air into the intermediate-acting insulin vial. Put air into the short-acting insulin vial. Withdraw the prescribed amount of short-acting insulin. Withdraw the prescribed amount of intermediate-acting insulin. Don a pair of clean gloves.

A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first?

Raise the head of the bed.

nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first?

Raise the head of the bed.

A client has a low hemoglobin level, which is attributed to nutritional deficiency, and the nurse provides dietary teaching. Which food choices by the client indicate that the nurse's instructions are effective? Select all that apply.

Raisins Spinach

Which clinical indicators does the nurse expect a client with Parkinson disease to exhibit? Select all that apply.

Resting tremors Flattened affect Slow voluntary movements

A nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify?

Retention of sodium and water

The nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of an adrenal cortex tumor. When assessing the client, which of these, if found, are signs of Cushing disease? Select all that apply.

Round face Dependent edema in the feet and ankles Thin, translucent skin with bruising Increased fatty deposition in the neck and back

A nurse notes that a client's urine has a sweet fruity odor. Which information is most important to evaluate when performing a further client assessment?

Serum glucose level

A nurse begins planning for the discharge of a client who had a brain attack (cerebrovascular accident, CVA) with residual hemiparesis and hemianopsia. What information should the nurse include in the discharge teaching plan for this client?

Significance of a safe environment

The nurse is interpreting the client's rhythm strip and finds that the P and QRS waves are consistent, with a P wave preceding every QRS complex. The PR interval is 0.26 seconds long. The rate is 64 beats per minute. The nurse interprets this rhythm as:

Sinus rhythm with first degree AV block.

A client has a diskectomy and fusion for a herniated nucleus pulposis. When getting out of the bed for the first time since surgery, the client reports feeling faint and lightheaded. The nurses assisting with the ambulation should have the client:

Sit on the edge of the bed so they can hold the client upright

A client is scheduled for a craniotomy to remove a brain tumor. To prevent the development of cerebral edema after surgery, the nurse anticipates the use of:

Steroids

A blood transfusion of packed cells has been prescribed for a client. The client shows signs of hemolytic reaction. Place the appropriate nursing actions in order.

Stop the transfusion Change IV administration set Run 0.9 normal saline at rapid rate Notify health care provider and blood bank

The health care provider prescribes one unit of packed red blood cells to be administered to the client who suffered a hip fracture. Several minutes after the start of the infusion, the client complains of itching. Upon further assessment, the nurse observes hives on the client's chest. Which action should the nurse take next?

Stop the transfusion immediately.

Following an injury to the spinal cord, a client experiences severe headache, paroxysmal hypertension, diaphoresis, nausea, and bradycardia that characterize episodes of autonomic hyperreflexia (autonomic dysreflexia). The nurse recognizes that the episodes occur if the spinal injury is at or above a specific level of the spinal cord. Using the illustration, fill in the specific level of the spinal cord in the blank.

T6

The nurse considers that a 70-year-old female can best limit further progression of osteoporosis by:

Taking supplemental calcium and vitamin D

The nurse is caring for a client with myasthenia gravis. The nurse expects which test to be ordered to differentiate a myasthenic crisis from a cholinergic crisis?

Tensilon

The nurse notes that the client's cardiac rhythm strips show more P waves than QRS complexes. There are no consistent PR intervals indicating that there is no relationship between the atria and the ventricles. The nurse realizes that the client is in:

Third degree AV block (complete heart block).

A nurse is performing a neurological assessment of a client. Which equipment is required when preparing to assess the vagus nerve (cranial nerve X) of a client?

Tongue depressor

A nurse is caring for a client who just had major abdominal surgery. What client responses indicate the possibility of developing a superficial venous thrombosis? Select all that apply. Tender area in the posterior lower leg

Warmth along the course of the involved vessel

The nurse is making rounds on a client who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? Select all that apply.

Wash hands before entering the client's room. Advise use of a soft toothbrush for oral hygiene. Report an elevation in temperature immediately.

The nurse is making rounds on a client who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? Select all that apply.

Wash hands before entering the client's room. Advise use of a soft toothbrush for oral hygiene. Report an elevation in temperature immediately.

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. The primary consideration in the care of this client is the need for:

control of pain

A client has surgery for the insertion of an implanted infusion port for chemotherapy. The client asks, "The doctor said after my chemotherapy is finished, the port will stay in, but it needs to be flushed routinely. How often does this have to be done?" What should the nurse tell the client about how often the port will most likely need to be flushed when not in use?

every month

A nurse explains to a client with trigeminal neuralgia that a treatment that is effective on a temporary (6 to 18 months) basis is:

An alcohol injection of the peripheral branch of the fifth cranial nerve

A nurse provides discharge teaching for a client who had a total hip replacement. Which statements made by the client indicate an understanding of the education? Select all that apply.

I should not cross my legs. I should not sit in a low chair.

The nurse notes that the client's rhythm strips show more P waves than QRS complexes. When there are PR intervals, they are all consistent. The nurse realizes that the client is in:

Second degree AV block Mobitz II.

A nurse is caring for a client in the home who has the diagnosis of amyotrophic lateral sclerosis (ALS). Which position should the nurse recommend that the client assume after eating?

Semi-Fowler

An older client exhibits typical clinical indicators of pulmonary edema. List the following clinical indicators of pulmonary edema in the order they typically appear.

1. crackles 2. increased respirations 3. tachycardia 4. orthopnea 5. frothy bloody tinged sputum

A client newly diagnosed with rheumatoid arthritis is admitted to the hospital with bilateral painful knee and wrist joints. The nurse identifies impaired physical mobility related to painful, swollen joints. What should the nurse teach the client to do during the acute phase of the disease?

Avoid exercises to the involved joints

The nurse is performing a neurological assessment on a client and notices Battle's sign. Place a mark on what part of the client's skull the nurse would view this sign?

Behind the ear

A beta-blocker, atenolol (Tenormin), is prescribed for a client with moderate hypertension. What information should the nurse include when teaching the client about this medication? Select all that apply.

Change positions slowly Count the pulse before taking the medication Mild weakness and fatigue are common side effects

A nurse is reviewing the physical examination and laboratory tests of a client with malaria. For which important clinical indicators should the nurse be alert when reviewing data about this client? Select all that apply.

Hyperthermia Splenomegaly

A nurse is caring for a client who was admitted to the hospital with a diagnosis of Addison disease. The nurse should assess the client for what signs related to this disorder?

Hypoglycemia and hypotension

A nurse is caring for a client with a diagnosis of Cushing syndrome. What is the most common cause of Cushing syndrome that the nurse should consider before assessing this client for physiological responses?

Hyperplasia of the adrenal cortex

A nurse is caring for a client with right-sided heart failure. Which are key features of right-sided heart failure? Select all that apply.

Dependent edema Distended abdomen Polyuria at night

A client is treated with lorazepam (Ativan) for status epilepticus. What effect of lorazepam does the nurse consider therapeutic?

Depresses the central nervous system (CNS).

Which significant risk factors for coronary heart disease carry a greater risk for women than for men? Select all that apply.

Diabetes mellitus Low levels of high-density lipoprotein (HDL) cholesterol

While assessing a client during a routine examination, a nurse in the clinic identifies signs and symptoms of hyperthyroidism. Which signs are characteristic of hyperthyroidism? Select all that apply.

Diaphoresis Weight loss Protruding eyes

A nurse concludes that a client has a hypoglycemic reaction to insulin. Which clinical findings support this conclusion? Select all that apply.

Irritability Heart palpitations

To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? Select all that apply.

Liver Shellfish

A health care provider prescribes doxorubicin for a client with acute myelogenous leukemia. Which specific interventions should the nurse implement? Select all that apply.

Monitor for jaundice Increase fluids by mouth Provide frequent oral care Assess vital signs routinely

Which medication should the nurse anticipate will be prescribed to relieve anxiety and apprehension in a client with pulmonary edema?

Morphine

Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Select all that apply.

Muffled heart soundsIncreased central venous pressure (CVP), Jugular vein distention

A client with heart failure is receiving digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). The nurse will assess for which signs and symptoms of digoxin toxicity? Select all that apply.

Nausea Yellow vision Irregular pulse

The nurse is caring for a client with diabetes. Which task can be delegated to the unlicensed assistant personnel (UAP)?

Obtain a blood glucose by finger stick

Place the steps to obtaining an orthostatic blood pressure assessment in order.

Obtain correct size blood pressure cuff Explain procedure to client Have client in supine position for five minutes and take blood pressure Assist client to a sitting position Obtain blood pressure in sitting position after waiting three minutes Have client stand and take blood pressure immediately Document blood pressures, pulses, and client tolerance

An older female client is seen in the health care provider office. Upon initial nursing assessment the nurse notes the client's height has decreased by 1 inch since the last visit one year ago. The nurse knows that what is the most likely reason for this finding?

Older adults may have osteoporosis-related height changes

A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply.

Pallor Tachycardia Narrow pulse pressure

What should a nurse do immediately when a client returns from the postanesthesia care unit following a subtotal thyroidectomy?

Place a tracheostomy set at the bedside.

A nurse is caring for a client with varicose veins. Which clinical manifestations should the nurse expect with this diagnosis? Select all that apply.

Presence of ankle edema Increased muscle fatigue Report of nocturnal leg cramps

The nurse is providing care to a client with acute arthritis who is on bed rest. The client reports bilateral painful and swollen knee and wrist joints. What position will help prevent flexion deformities during the acute phase of this client's care?

Prone

The nurse is caring for a client with increased intracranial pressure (ICP). What clinical manifestations are associated with increased ICP? Select all that apply.

Psychotic behaviors Jacksonian seizures Nausea and vomiting

A client had a cerebrovascular accident (also known as a "brain attack") and bed rest is prescribed. What can the nurse use to best prevent footdrop in this client?

Splints

A nurse is caring for a client who just had a thyroidectomy. For which client response should the nurse assess the client when concerned about an accidental removal of the parathyroid glands during surgery?

Tetany