Final

A client has been prescribed Dilaudid (hydromorphone) 0.25 mg intravenously (IV) every 2 hours prn pain. Available is an ampule labeled 2 mg / 1 mL. How many mL will the nurse administer? (round to the hundredths)

0.13mL

A client is ordered a dose of epoetin alfa (Procrit). The recommended dose is 100 units/kg. The client weighs 70 kg. The vial is labeled 10,000 units/mL. How many mL should the nurse administer?

0.7 mL

A client is prescribed regular intravenous (IV) insulin 0.1 units / kg/ hr by continuous infusion. The client weighs 85 kg. How many units of insulin will the client receive each hour?

8.5 units per hour

The client is prescribed an oral morphine solution. The label states to take 2 tablespoons every 6 hours as needed. The nurse is explaining how to measure this dose accurately by using milliliters. What is the dose in mL?

30mL

A client is to receive 1000 mL of 0.9% Sodium Chloride intravenously (IV) administered over 8 hours. What is the IV gravity flow rate if the nurse uses IV tubing with a drop factor of 15 gtt/mL?

31gtts/min

Match the gland with the secreted hormone. 1. Posterior Pituitary 2. Adrenal 3. Anterior Pituitary 4. Thyroid Options: -ADH -Glucocorticoid -Growth Hormone -T3, T4

1. ADH 2. Glucocorticoid 3. Growth Hormone 4. T3, T4

A client is to receive 250 mL of intravenous (IV) fluid to be administered over 120 minutes using 20 gtt/mL tubing. What flow rate will the nurse set on the IV pump?

125 mL/hr

A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output?

1370 mL

A client is to receive a heparin infusion at 1300 units per hour. A premixed bag of 25,000 units in 250 mL of dextrose in water is available for the drip. The tubing has a drip factor of 15 gtt/mL. What rate will the nurse set on the IV pump?

13mL/hr

The nurse should administer 500 mL of intravenous solution over 3 hours to a client. Using tubing with a drip factor of 12 gtt/mL calculate the gravity flow rate.

33 gtts/min

The client's heparin is infusing at 24 mL/hr on an IV pump. The bag of fluid is mixed 20,000 units of heparin in 500 mL D5 How many units of heparin is the client receiving per hour?

960 units/hour

Which of the following serum lab values would a nurse anticipate to be increased in a client with chronic renal failure? Choose all that apply. A. Creatinine B. Calcium C. Potassium D. Phosphorus E. Hemoglobin

A. Creatinine C. Potassium D. Phosphorus

A client has been prescribed Ancef (Cefazolin) 250 mg in 100 mL of D5W to be infused intravenously (IV) over 30 minutes using 15 gtt/mL IV tubing. What flow rate will the nurse set on the IV pump?

200mL/hr

A client has been prescribed ceftriaxone (Rocephin) 1 g in 100 mL 0.9% sodium chloride over 30 minutes. The drop factor on the IV tubing is 20 gtt/mL. What rate will the nurse set on the IV pump?

200ml/hr

A client is to receive Regular Insulin 2 units per hour intravenously (IV) by continuous infusion. Pharmacy sends a bag with Regular Insulin 100 units in 100 mL 0.9% sodium chloride. What rate will the nurse set on the IV pump?

2ml/hr

The prescribers orders state to administer IV fluids to a total of 75 mL/hr. There is a Morphine drip running at 2 mL/hour and an order to start an infusion of 0.9% Sodium Chloride. What rate should the nurse set the IV pump in order to administer the 0.9% sodium chloride?

73mL/hr

The nurse is providing care to a client with terminal bone cancer. The client has a double lumen PICC line. Pharmacy sends an IV bag of Dilaudid 50 mg in 100 mL D5W. Prescriber's Order Sheet hydromorphone (Dilaudid) 2 mg/hr intravenously 0.9% sodium chloride intravenously (IV) The total hourly rate of all IV fluids should equal 50 mL/hr. -J. Romito, MD What rate should the nurse set on the IV pump in order to administer Dilaudid 2 mg/hr?

4 ml/hr

The nurse is caring for a client with acute kidney disease. The client weighs 60 kg. The physician prescribes Dopamine 2 mcg/kg/min. Pharmacy sends Dopamine 400 mg in 250 mL of D5W. What rate will the nurse set on the IV pump?

4.5 mL/hr

A client is to receive 1000 mL 5% Dextrose in Water over 8 hours. The drop factor on the IV tubing is 20 gtt/mL. What is the gravity flow rate?

42gtts/min

A nurse is preparing to administer albuterol syrup 1.6 mg PO tid. Available is albuterol 2 mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

4mL

The client has an order to administer a potassium replacement IV. The provided dose is 20 meq of potassium chloride in 250 mL to be administered over 4 hours. At what rate will the IV pump be set?

62.5mL/hr

Which of the following data would a nurse use to evaluate a client's fluid status after hemodialysis? A. Vital signs and weight. B. Creatinine level and weight. C. Sodium level and weight. D. Potassium level and weight.

A. Vital signs and weight.

The nurse instructs a client receiving external radiation therapy about skin care. Which statement by the client indicates an understanding of the instructions? A. "I can lie in the sun as long as I limit the time to 2 hours a day." B. "After bathing, I should pat the area dry using a clean soft towel." C. "I should wash the irradiated area gently each day with betadine." D. "I should wear snug clothing to support the irradiated skin area."

B. "After bathing, I should pat the area dry using a clean soft towel."

Which statement indicates that the client understands teaching about neutropenia? A. "I need to avoid flossing my teeth." B. "I need to avoid places that are crowded with people." C. "I can give other people an infection." D. "I have to wear a mask at all times."

B. "I need to avoid places that are crowded with people."

A nurse is developing a plan of care to replace fluids for a patient in the oliguric phase of acute kidney disease. The client has a 24-hour fluid output of 300 ml emesis and 200 ml urine. How much fluid will the nurse plan to replace? A. 1000 mL B. 1100 mL C. 450 mL D. 900 mL

B. 1100 mL

In clients with any type of acid-base imbalance, the nurse places the priority on monitoring which electrolyte? A. Sodium B. Potassium C. Calcium D. Magnesium

B. Potassium

A nurse is providing discharge teaching for a client who is to receive long-term prednisone (Deltasone). Which of these statements should the nurse include in the discharge instructions? A. "This medication decreases chances of infections." B. "This medication will be discontinued after two doses." C. "Do not abruptly stop taking this medication." D. "If your face becomes puffy, the medication dose needs to be increased."

C. "Do not abruptly stop taking this medication."

A client being discharged from the hospital will be taking warfarin sodium (Coumadin) at home on a daily basis. The nurse has provided instructions to the client about the medication and determines that further teaching is needed if the client makes which statement? (Select all that apply) A. "This medication thins my blood and allows me to clot more slowly." B. "If I notice any increased bleeding or bruising, I need to call my doctor." C. "I need to increase the intake of foods high in vitamin K in my diet." D. "I need to have my potassium monitored weekly."

C. "I need to increase the intake of foods high in vitamin K in my diet." D. "I need to have my potassium monitored weekly."

Which client statement indicates understanding of chronic syndrome of inappropriate antidiuretic hormone (SIADH)? A. "I should weigh myself monthly and report sudden weight loss or gain." B. "I need to limit my sodium to 1 gram a day." C. "I should eat foods high in sodium." D. "I need to shop for foods low in sodium and avoid adding salt to food."

C. "I should eat foods high in sodium."

A middle-aged client is having a physical examination and is worried about cancer risk. Which question is most important for the nurse to ask? A. "How much time do you spend in the sun?" B. "How often do you eat processed meats like bologna?" C. "How many servings of fruits and vegetables do you eat every day?" D. "Do you smoke cigarettes or have you ever used tobacco products?"

D. "Do you smoke cigarettes or have you ever used tobacco products?"

The client with Addison's disease is ordered glucocorticoid therapy. Which of the following statements indicates that the client has a correct understanding of the disease and medication regimen? A. "I am on every-other-day- dosing regimen." B. "I will adjust my dosages based on my home blood glucose test results." C. "On days I feel good, I will not need to take the medication." D. "I need to wear an identification bracelet stating I have Addison's disease."

D. "I need to wear an identification bracelet stating I have Addison's disease."

A client with renal cell carcinoma of the left kidney is scheduled for a nephrectomy. The right kidney appears normal at this time. The client is anxious about whether dialysis will ultimately be necessity. How will the nurse respond? A. "Dialysis could become likely, but it depends on how well you comply with fluid restriction after surgery." B. "There is a strong likelihood that you will need dialysis within 5 to 10 years." C. "There is no chance of needing dialysis because the body can function with one kidney." D. "One kidney is adequate to meet the needs of the body as long as the kidney is functioning normally."

D. "One kidney is adequate to meet the needs of the body as long as the kidney is functioning normally."

The client with Pheochromocytoma is complaining of a pounding headache. Upon assessment, the nurse notes a bounding, fast pulse and the patient is flushed. The vital signs show blood pressure 229/117, heart rate 168, respiratory rate is 26, SpO2 97% on room air, temperature is 99.4 oral. After notifying the physician, the nurse anticipates and order for: A. methylprednisone B. Vasopressin C. romazicon D. metoprolol

D. metoprolol

After receiving change-of-shift report, which client does the nurse assess first? The client with... A. stomatitis who is experiencing mouth pain that is rated a 4/10 on the pain scale. B. lung cancer whose chemotherapy is scheduled to begin. C. ovarian cancer who received news that the cancer has spread and is crying. D. neutropenia who was just admitted to the unit with fever of unknown origin.

D. neutropenia who was just admitted to the unit with fever of unknown origin.

The nurse is performing an admission assessment on a client diagnosed with colorectal tumor. The nurse asks the client about which characteristic symptom of this type of tumor? (Select all that apply) A. Weight gain B. Change in bowel habits C. Abdominal pain D. Increased hunger pains E. Blood in the stool

E. Blood in the stool

A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.) A. Moon Face B. Amennorhea C. Purple striations D. Tremors E. Alopecia

A, B, C, E

When explaining hospice care to a client, which of the following statements is most appropriate? A. "Clients and their families are the focus of care." B. "All hospice clients will die at home." C. "Hospice care uses a team approach to direct hospice activity." D. "The client's physician coordinates all the care."

A. "Clients and their families are the focus of care."

During the nursing assessment, the client says, "My doctor just told me that my cancer has spread and that I have less than 6 months to live." Which of the following nursing responses would be therapeutic? A. "I am sorry. Would you like to discuss this with me some more?" B. "I know it seems desperate, but new research is being done that might treat your cancer." C. "I am sorry. There are no easy answers in times like this, are there?" D. "I hope you'll focus on the 6 months you have and you'll think of how you'd like to live."

A. "I am sorry. Would you like to discuss this with me some more?"

A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction? A. "I can detect the presence of carbon monoxide by a metallic odor." B. "Breathing in carbon monoxide can cause headaches and nausea." C. "I should purchase a carbon monoxide detector for my home." D. "A high concentration of carbon monoxide can cause death."

A. "I can detect the presence of carbon monoxide by a metallic odor."

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? A. "It is caused by the lack of production of aldosterone by the adrenal gland." B. "It is caused by the increase in production of growth hormone by the hypothalamus." C. "It is caused by an increase in production of aldosterone by the adrenal gland." D. "It is caused by the lack of production of calcitonin by the thyroid."

A. "It is caused by the lack of production of aldosterone by the adrenal gland."

Which is the best instruction for the nurse to give a client scheduled for a Radioactive Iodine Uptake Exam [I-123]? A. "No special radiation precautions are needed." B. "Your thyroid will be radioactive for weeks." C. "You will have external beam radiation." D. "No radiation is used for this scan."

A. "No special radiation precautions are needed."

A client has known lung cancer and has been admitted for abdominal pain and jaundice. A computed tomography (CT) scan reveals tumors in the client's liver. The client is upset and says, "So now I have liver cancer too?" Which response by the nurse is most appropriate? A. "No, the tumors are most likely from your lung cancer, which has metastasized." B. "No, having tumors in two different organs is rare; you probably have hepatitis." C. "Yes, liver cancer is common in people who already have lung cancer." D. "Yes, your chemotherapy left you vulnerable to a virus that causes liver cancer."

A. "No, the tumors are most likely from your lung cancer, which has metastasized."

After receiving change-of-shift report, which of these patients should the nurse assess first? A. A 75 year old man with metastatic prostate cancer with a fracture of the femur who is in pain. B. A 27-year old man with leukemia who is scheduled to begin high-dose chemotherapy C. A 23- year old woman who is experiencing nausea. D. A 38-year-old woman receiving internal radiation therapy for cervical cancer.

A. A 75 year old man with metastatic prostate cancer with a fracture of the femur who is in pain.

A nurse is monitoring the function of a client's chest tube attached to an Atrium Wet Drainage System. The nurse notes that the fluid in the water seal chamber is below the required level. Which of the following actions should the nurse perform? A. Add water to the water seal chamber. B. Replace the drainage system. C. Connect the system to wall suction. D. Assess the chest tube for the site of an air leak.

A. Add water to the water seal chamber.

The client is admitted to the endocrinology unit newly diagnosed with an acute exacerbation of diabetes insipidus. Which intervention is the priority nursing action? A. Administer intravenous fluids. B. Monitor the client's intake and output. C. Obtain the client's baseline weight. D. Assess urine specific gravity.

A. Administer intravenous fluids.

A client with chronic kidney disease is scheduled for hemodialysis and is scheduled to receive a daily dose of lisinopril (Zestril). When should the nurse plan to administer this medication? A. After dialysis B. Two hours prior to dialysis C. The day after dialysis D. Just prior to dialysis

A. After dialysis

A nurse is caring for a client who is unable to eat due to stomatitis. Which nursing action will be most effective in improving oral intake? A. Apply the ordered anesthetic gel to oral lesions before meals. B. Encourage frequent mouth care with antiseptic mouthwash. C. Instruct the client to use an electric toothbrush. D. Offer the client frequent small snacks between meals.

A. Apply the ordered anesthetic gel to oral lesions before meals.

The nurse is teaching the client who is receiving chemotherapy, and the family, how to manage possible nausea and vomiting at home. Which information should the nurse include in the education? A. Eat frequent small meals throughout the day. B. Eat three smaller sized meals a day. C. Eat 30 minutes after taking pain medication. D. Decrease the amount of fluid intake.

A. Eat frequent small meals throughout the day.

A client is being admitted with suspected syndrome of inappropriate antidiuretic hormone (SIADH). The nurse anticipates and order for which of the following: (select all that apply) A. CT scan of the head B. 3% Sodium Chloride IV infusion C. Administer furosemide D. Implement seizure precautions E. Begin water deprivation testing

A. CT scan of the head B. 3% Sodium Chloride IV infusion C. Administer furosemide D. Implement seizure precautions

The nurse administers calcium gluconate intravenously to a client with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the medication? A. Cardiac rhythm B. Calcium level C. Urine volume D. Blood pressure

A. Cardiac rhythm

The nurse, providing care to a client in the oliguric stage of renal failure, notes the following assessment data: * Respiratory rate of 20 * SpO 2 93% on room air * Irregular heart rate The client complains of nausea, a dull headache, palpitations and general malaise. Which of the following nursing actions has the highest priority? A. Check for the latest electrolyte values. B. Educate the client on the importance of avoiding nephrotoxic medications. C. Call the physician. D. Administer prescribed acetaminophen (Tylenol).

A. Check for the latest electrolyte values.

The nurse is caring for a client with end-stage colon cancer. What areas are appropriate to assess to determine the client's wishes for end-of-life nursing care? (Select all that apply) A. Client expectations for nursing care B. Financial responsibilities for the funeral C. Expectations regarding pain control and symptoms management. D. Where are the funeral and burial will take place E. Use of and level of life-sustaining measures.

A. Client expectations for nursing care C. Expectations regarding pain control and symptoms management. E. Use of and level of life-sustaining measures.

After receiving change-of-shift report, which client should the nurse assess first? A. Client just returned from hemodialysis with pulse of 122/min and blood pressure 86/43. B. Client with stage 4 chronic kidney disease who has an elevated phosphate level. C. Client with stage 4 chronic kidney disease who has a calcium level of 8.7 md/dL. D. Client who is scheduled for the drain phase of a peritoneal dialysis exchange.

A. Client just returned from hemodialysis with pulse of 122/min and blood pressure 86/43.

A client with diabetes mellitus has influenza. Which instruction should the nurse include in the teaching plan? (Select All That Apply) A. Continue use of insulin, even if unable to eat. B. Increase the frequency of blood glucose testing. C. Reduce food intake to diminish nausea. D. Take half of the normal dose of insulin. E. Notify physician if unable to tolerate food and drink.

A. Continue use of insulin, even if unable to eat. B. Increase the frequency of blood glucose testing. E. Notify physician if unable to tolerate food and drink.

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with thick bronchial secretions? A. Encouraging the client to drink 2 to 3 L of water daily. B. Administering oxygen via nasal cannula at 2 L/min. C. Helping the client select a low-salt diet. D. Maintaining a semi-Fowler's position as often as possible.

A. Encouraging the client to drink 2 to 3 L of water daily. (COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.)

The nurse is caring for a client admitted to the hospital with diabetes insipidus. Which complaint by the patient would the nurse anticipate? A. Fatigue B. Swollen feet C. Difficulty breathing D. Difficulty urinating

A. Fatigue

A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? A. Flexing their knees and feet frequently B. Applying cool compresses to their legs C. Wearing loose, non-constricting stockings D. Taking an NSAID tablet daily

A. Flexing their knees and feet frequently

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was A. Hoarseness B. Weight Loss C. Dysphagia D. Dyspnea

A. Hoarseness

A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect? A. Hyperpigmentation B. Intention tremors C. Hirsutism D. Purple striations

A. Hyperpigmentation

A nurse is assessing a client who has prerenal acute kidney injury (AKI). Which of the following findings should the nurse expect? A. Hypotension. B. Delayed capillary refill. C. Clear lung sounds. D. Restlessness.

A. Hypotension.

A client is being treated for deep vein thrombosis. The physician has prescribed 60 mg of enoxaparin (Lovenox) subcutaneously. Before administering the drug, the nurse checks the client's laboratory results, noted below: Laboratory results Test Results Prothrombin time INR Platelet count 12.5 seconds 2.0 50 x 103µL (50,000 / µL) What priority action should the nurse perform? (Select all that apply) A. Inform the physician. B. Instruct the client to report signs of bruising. C. Withhold the dose of Lovenox. D. Prepare to administer Fresh Frozen Plasma. E. Request a repeat PT/INR.

A. Inform the physician. B. Instruct the client to report signs of bruising. C. Withhold the dose of Lovenox.

A client on 3L of oxygen via nasal cannula has shallow respirations, fine crackles in bilateral lower lung fields, and diminished breath sounds since the last assessment 4 hours ago. The nurse's current assessment findings include: Heart rate: 78 Blood pressure: 110/70 Temperature: 99 degrees Fahrenheit SPO2 : 90% 3L/nc No extremity edema Which action by the nurse is most appropriate? A. Instruct the client to use the spirometer and to cough. B. Ensure that the ordered oxygen therapy is being provided. C. Consult with the health care provider and request an order for diuretics. D. Call respiratory therapy and request a bronchodilator treatment.

A. Instruct the client to use the spirometer and to cough.

A client has metabolic acidosis. The nurse plans to assess for which manifestation consistent with this condition? A. Kussmaul respirations B. Agitation C. Hypertension D. Seizures

A. Kussmaul respirations

The nurse is caring for a client with a diagnosis of pneumothorax. The client is being treated with a chest tube. Which of the following actions should the nurse perform? (Select all that apply) A. Maintain an occlusive dressing around chest tube at insertion site B. Report tidaling in water seal section of chest drainage system C. Milk chest tubes hourly to promote chest drainage D. Keep chest drainage system lower than client's chest E. Clamp chest tube when assisting client from bed to chair

A. Maintain an occlusive dressing around chest tube at insertion site D. Keep chest drainage system lower than client's chest

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? A. Movement of the trachea toward the unaffected side. B. Crepitus in the area above and surrounding the insertion site. C. The chest tube sutures are not visible. D. Bubbling of the water in the water seal chamber with exhalation.

A. Movement of the trachea toward the unaffected side. (An assessment of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of tension pneumothorax and should be reported to the provider immediately.)

Standing protocol for adjusting heparin by aPTT levels aPTT (seconds) Bolus/Hold Infusion Rate Change <36 Bolus 20 units/kg & inform MD Increase 2 units/kg/hr 36-37 0 Increase 1 unit/kg/hr 38-46 0 No Change 47-56 0 Decrease 1 unit/kg/hr 57-66 0 Decrease 2 units/kg/hr 67-86 Hold infusion 1 hr & inform MD Decrease 2 units/kg/hr 87-100 Hold infusion 1 hr & inform MD Decrease 3 units/kg/hr >100 Hold infusion 1 ½ hr & inform MD Decrease 4 units/kg/hr A client is receiving a heparin drip and is on the heparin protocol provided above. The nurse receives an aPTT (activated partial thromboplastin time) result of 140 seconds. Which of the following actions should the nurse perform? (Select all that apply) A. Notify the physician B. Assess the client. C. Prepare to administer vitamin K D. Increase the drip per facility protocol E. Hold the drip per facility protocol

A. Notify the physician B. Assess the client. E. Hold the drip per facility protocol

A client is 5 days post-op from a kidney transplant. The nurse assesses the client's foley bag and notes that the urine is cloudy. What action should the nurse perform? A. Notify the physician. B. Irrigate the urinary catheter. C. Record the finding in the intake record. D. Increase the intravenous flow rate.

A. Notify the physician. (Cloudy urine indicates infection. In order to treat infection, the physician needs to order these treatments.)

A client is admitted with a suspected opioid overdose and a respiratory rate of 8 respirations per minute. Which of the following assessment data would the nurse anticipate? (Choose all that apply) A. PaCO2 54 mm Hg B. HCO3 17 mEq/L C. PaO2 92 mm Hg D. pH 7.29

A. PaCO2 54 mm Hg D. pH 7.29

To identify whether a client has a flail chest, which of these assessment techniques should a nurse perform? A. Palpate and inspect respiratory movements. B. Percuss anterior and posterior thorax. C. Auscultate breath sounds in all lung fields. D. Obtain pulse oximetry and respiratory rate.

A. Palpate and inspect respiratory movements.

The nurse at a clinic is interviewing a 51 year old who woman who is 5 feet, 4 inches tall and weighs 130 pounds. The client has not seen a healthcare provider for 15 years. She walks outdoors for 3 miles most days and has a glass of beer 2 times a week. Which topics will the nurse include in the teaching plan for cancer screening and decreasing cancer risk? (Select all that apply) A. Pap testing B. Mammography C. Colorectal screening D. PSA testing E. Sunscreen use

A. Pap testing B. Mammography C. Colorectal screening E. Sunscreen use

Which of the following interventions should the nurse implement to prevent infection in a hospitalized immunocompromised client? (Select all that apply). A. Perform oral care after every meal. B. Place disposable stethoscope in the client's room to use when assessing the client. C. Do not allow fresh flowers and potted plants in the client's room. D. Place the client in a semi-private room with another client who is immunocompromised. E. Administer enemas and suppositories to avoid constipation.

A. Perform oral care after every meal. B. Place disposable stethoscope in the client's room to use when assessing the client. C. Do not allow fresh flowers and potted plants in the client's room.

A client is receiving IV insulin for hyperglycemia. Which laboratory value requires immediate intervention by the nurse? A. Potassium level of 2.8 mEq/L B. Magnesium level of 2.1 mEq /L C. Sodium level of 133 mEq /L D. Calcium level of 10.2 mg/dL

A. Potassium level of 2.8 mEq/L

A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.) A. Potatoes B. Asparagus C. Bread D. Bananas E. Green Beans

A. Potatoes D. Bananas

A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? (Select all that apply). A. Pruritus B. Slurred speech C. Bone pain D. Hypotension E. Bradypnea

A. Pruritus C. Bone pain

A client with type 2 diabetes is to receive a CT of the brain with IV contrast. Which information is most important for the nurse to report to the health care provider? A. The client received metformin (Glucophage) this morning. B. The client received tenolol (Tenormin) this morning. C. The client' admission blood glucose is 130 mg/dL D. The client's HgA1C is 5.8%.

A. The client received metformin (Glucophage) this morning.

A client with terminal cancer has requested hospice services. Which of the following excludes a patient from meeting criteria for hospice care? A. The client states he wants to continue to receive chemotherapy. B. The prescriber orders an antibiotic to treat a client's urinary tract infection. C. The client says that he does not want to talk about dying. D. The client explains they are not ready to look at funeral homes.

A. The client states he wants to continue to receive chemotherapy.

A client diagnosed with lymphoma received chemotherapy 2 days ago. The nurse notes the following lab values: Lab Results Potassium: 5.8 mEq/L Calcium: 6.5 mg/dL Phosphorous: 6.2 mg/dL Uric acid: 9 mg/dL Which of the following oncological emergencies should the nurse suspect? A. Tumor Lysis Syndrome B. Superior vena cava syndrome C. Hypercalcemia D. Spinal cord compression

A. Tumor Lysis Syndrome

A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take? A. Verify the most recent calcium level. B. Request prescription for a relaxant. C. Administer an oral potassium supplement. D. Check the pedal pulses.

A. Verify the most recent calcium level.

A client is diagnosed with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Which of the following assessment data would the nurse expect the client to manifest? A. Weight gain and decreased level of consciousness. B. Increased urinary output. C. Decreased blood pressure and decreased pedal pulses. D. Decreased specific gravity of the urine.

A. Weight gain and decreased level of consciousness.

Which of the following clinical manifestations would indicate to a nurse that a client with superior vena cava syndrome is improving? The client's... A. hands are less edematous. B. back pain is relieved. C. breath sounds are clear bilaterally. D. feet have 4+ edema present.

A. hands are less edematous.

A client diagnosed with colon cancer with metastasis to the bone rates his pain a 7 on the 0/10 pain scale. He has no evidence of tachycardia, hypertension, diaphoresis, or pallor. Based on this data, what should the nurse conclude about the client's pain? The client.... A. is experiencing chronic pain. B. is experiencing intermittent pain. C. does not really have a pain level of 7/10. D. is receiving adequate pain medication.

A. is experiencing chronic pain.

The nurse is providing care to a client with syndrome of inappropriate antidiuretic hormone (SIADH). What instructions should the nurse give to the nursing assistant? The client: A. is on a water restriction. B. may drink as much water as they like. C. should be encouraged to increase their water intake. D. is NPO.

A. is on a water restriction.

The nurse is working in an outpatient client triaging phone calls. Which client warrants notifying the healthcare provider? The client with A. type 1 diabetes who had a kidney transplant and reports decreased urine output and flu-like symptoms. B. type 2 diabetes receiving hemodialysis who has gained 6 pounds since the last dialysis treatment. C. type 1 diabetes who has early stage chronic renal disease and reports having to go to the bathroom several times at night. D. syndrome of inappropriate antidiuretic hormone who is very upset because no one has returned the previous phone call.

A. type 1 diabetes who had a kidney transplant and reports decreased urine output and flu-like symptoms.

The nurse is teaching a client with diabetes about exercise. Which statement by the client indicates a correct understanding of the instructions? A. "I should exercise 30 minutes twice a week, preferably before eating a meal." B. "I will not exercise if my blood glucose is over 250 and my urine has ketones." C. "Exercise can help increase my risk for stroke and heart disease." D. "If I have ketones in my urine, I should exercise more vigorously."

B. "I will not exercise if my blood glucose is over 250 and my urine has ketones."

A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find I have cancer." Which of the following responses should the nurse make? A. "I'm looking at your chart here and I don't see any reason for you to worry about that." B. "I'm hearing that you are concerned that it might turn out that you have cancer." C. "I think that's something you need to discuss with your provider." D. "Why do you think you might have cancer when your diagnosis is a benign condition?"

B. "I'm hearing that you are concerned that it might turn out that you have cancer."

A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should the nurse make? A. "Antidepressants are not your solution, but this therapy group is." B. "Let's discuss what you mean when you say that you cannot ever return to work." C. "You need to work hard on resolving conflict with those closest to you." D. "I notice you keep clenching your fists. This needs to stop."

B. "Let's discuss what you mean when you say that you cannot ever return to work."

At the "Prostate Health" booth at the community health fair, the nurse responds to several clients' questions in regards to the prostate specific antigen (PSA) test. Which statement would the nurse include in teaching clients about the PSA test? A. "Yearly PSA screening should begin at age 40 in all men." B. "The PSA test should be performed before a digital rectal exam." C. "Normal values vary with age and decrease as you get older." D. "You should fast for eight hours prior to having the specimen obtained."

B. "The PSA test should be performed before a digital rectal exam."

A client has developed chronic renal failure and says to the nurse, "This means that I will die very soon." The nurse makes which appropriate response to the client? A. "You don't need to worry, you will do just fine with hemodialysis." B. "You sound discouraged today." C. "Why do you think that?" D. "Are you tired of following the diet restrictions?"

B. "You sound discouraged today."

A client has stage 4 breast cancer with metastasis to the bones. Which priority nursing intervention does the nurse add to the client's care plan? A. Encourage the client to drink milk at each meal. B. Administer pain medications around the clock. C. Ensure that the client gets adequate rest. D. Provide snacks that are high in calories.

B. Administer pain medications around the clock.

The nurse assesses that a client is at risk for developing disseminated intravascular coagulopathy (DIC). Which of the following laboratory findings should be reported to the physician immediately? A. Activated partial thromboplastin time (aPTT) of 35 seconds B. Fibrinogen level 84 mg/dL C. Hgb 13 gm/dL D. Prothrombin time (PT) 12 seconds

B. Fibrinogen level 84 mg/dL

A nurse, at a community health fair, is providing education about general measures to avoid excessive sun exposure. Which of the following recommendations is appropriate? A. Wear loosely woven clothing that is made primarily from cotton fibers. B. Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure. C. Avoid peak exposure hours from 9 am to 1 p.m. D. Apply sunscreen only after going into the water.

B. Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure.

A client has the following arterial blood gases (ABGs): pH 7.20 HCO3 22 mEq/L PCO2 75 mm Hg PaO2 82 mm Hg. Which intervention by the nurse takes priority? A. Administering mucolytics B. Assessing and maintaining the airway C. Administering bronchodilators D. Providing oxygen

B. Assessing and maintaining the airway

An adult with type 2 diabetes mellitus has been NPO since 2400 in preparation for having a nephrectomy the next day. At 0700 on the day of surgery, the nurse reviews the client's chart and laboratory results. Which finding should the nurse report to the physician? A. Urine specific gravity of 1.017. B. Blood glucose of 455 mg/dL. C. Potassium of 3.9 mEq/L. D. Urine output of 325 mL in 8 hours.

B. Blood glucose of 455 mg/dL.

A client has been admitted with Hypoparathyroidism. The client's laboratory values are as follows: Lab Values Calcium 7.7 mg/dL Sodium 139 mEq/L Potassium 5.2 mEq/L Which medication does the nurse anticipate administering? A. Calcitriol (Rocaltrol) orally B. Calcium chloride IV C. 3% NS IV solution D. Potassium chloride IV

B. Calcium chloride IV

A nurse in a provider's clinic is assessing a client who has cancer and a prescription for methotrexate PO. Which of the following actions should the nurse take when the client reports bleeding gums? A. Instruct the client to use an electric toothbrush. B. Check the value of the client's current platelet count. C. Have the client make an appointment to see the dentist. D. Explain to the client that this is an expected adverse effect.

B. Check the value of the client's current platelet count.

A nurse in the endocrine clinic has obtained the following medication history and data from a client who has been taking prednisone (Deltasone) 40 mg daily for 5 weeks. Which is the most important to report to the health care provider? A. Client has bilateral 1+ pitting pedal edema. B. Client abruptly stopped taking the medication 2 days ago. C. Client has not been taking the prescribed vitamin D. D. Client's blood pressure is 148/90 mm Hg.

B. Client abruptly stopped taking the medication 2 days ago.

A nurse is planning care for a client newly diagnosed with acute deep vein thrombosis of the left leg. The client reports a pain level of 8/10 in his left calf. The nurse assess 4+ edema in the client's left lower leg. Which intervention would the nurse include in the care of this client? A. Ambulate in the hall three times per shift. B. Elevate the left leg. C. Apply ice to right leg twice per day. D. Administer 5000 units heparin subcutaneously daily.

B. Elevate the left leg.

A nurse is caring for a patient with arterial blood gas values of: pH 7.33 PCO2 48 mm Hg HCO3 25 mEq/L PaO2 90 Which of the following actions should the nurse perform? A. Obtain an order for a loop diuretic. B. Encourage adequate hydration to keep mucous membranes moist. C. Have the client breathe deeply and slowly into a paper bag. D. Monitor serum calcium levels.

B. Encourage adequate hydration to keep mucous membranes moist.

A nurse is providing care to client with a right chest tube connected to an Atrium chest drainage system. Which of the following actions should the nurse perform? A. Empty the collection chamber once a shift. B. Encourage the client to cough and deep breathe every hour C. Position the client only on the back and on the right side D. Maintain the client on bed rest until the chest tube is removed.

B. Encourage the client to cough and deep breathe every hour

A 55-yr-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication? * Creatinine 1.6 mg/dL * Oxygen saturation 89% * Hemoglobin level 13 g/dL * Blood pressure 98/56 mm Hg A. Oxygen saturation 89% B. Hemoglobin level 13 g/dL C. Blood pressure 98/56 mm Hg D. Creatinine 1.6 mg/dL

B. Hemoglobin level 13 g/dL

A client on oxygen at a flow rate of 5 L/min by nasal cannula is experiencing nasal passage discomfort. What intervention should the nurse perform to improve the client's comfort for this problem? A. Apply vaseline to the clients nares. B. Humidify the oxygen. C. Pad the oxygen tubing with gauze. D. Place the client on a simple face mask.

B. Humidify the oxygen.

A nursing is providing dietary teaching for a client who has Cushing's disease. Which statement made by the patient would require follow up by the nurse? A. Avoid green leafy vegetables. B. Increase sodium intake. C. Increase protein intake. D. Limit carbohydrates.

B. Increase sodium intake.

A client is to receive radioactive iodine therapy, I - 131, to treat Graves' disease. Which action should the nurse perform? A. Instruct the client to drink the iodine without a straw so that she gets the full dose. B. Instruct the client to flush the toilet 2-3 times after each use for 3 days after therapy. C. Assess the client's temperature to use as a baseline for evaluation purposes. D. Assess the client for hypersensitivity by asking if she is allergic to eggs.

B. Instruct the client to flush the toilet 2-3 times after each use for 3 days after therapy.

Which information should the nurse include in the teaching plan for a client who is receiving warfarin sodium (Coumadin)? A. Protamine sulfate is used to reverse the effects of warfarin sodium. B. International Normalized Ratio (INR) is used to assess effectiveness. C. Warfarin sodium will facilitate clotting of the blood. D. D-dimer values determine the dosage of warfarin sodium.

B. International Normalized Ratio (INR) is used to assess effectiveness.

The client with acute renal failure asks the nurse for a snack. Which of the following snacks is most appropriate? A. Orange juice. B. Jello. C. Cottage cheese. D. Yogurt.

B. Jello

Which of these manifestations should a nurse investigate first when assessing a client who is receiving chemotherapy? A. Dry mucous membranes B. Large areas of ecchymosis on extremities C. Complaints of fatigue D. Hair loss on scalp

B. Large areas of ecchymosis on extremities

Following a subtotal thyroidectomy, the nurse asks the client to speak immediately upon regaining consciousness. The nurse does this to monitor for signs of which of the following? A. Internal hemorrhage. B. Laryngeal nerve damage. C. Upper airway obstruction. D. Decreasing level of consciousness.

B. Laryngeal nerve damage.

A nurse is collecting the medical history from a client who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if he has a history of which of the following conditions that can cause SIADH? A. Liver cirrhosis B. Lung cancer C. Osteoarthritis D. Dyspepsia

B. Lung cancer

The nurse is planning care for a patient with severe heart failure who has developed increased blood urea nitrogen (BUN) and creatinine levels. What will be the primary treatment goal in the plan? A. Diluting nephrotoxic medications B. Maintaining cardiac output C. Preventing hypertension D. Increase fluid volume

B. Maintaining cardiac output

A client in the ER is being admitted with diabetic ketoacidosis. The nurse starts and insulin drip per orders. The client begins complaining of heart palpitations and the nurse notes premature ventricular contractions on the heart monitor. Which of the following orders would the nurse complete first? A. Check a blood glucose level. B. Obtain a serum potassium level. C. Stop the insulin drip. D. Administer calcium gluconate IV.

B. Obtain a serum potassium level.

When assessing a client who is receiving peritoneal dialysis, which of these findings would indicate a peritoneal infection? A. Decreased body temperature. B. Outflow of dialysis solution is cloudy. C. Incomplete draining of dialysis solution from peritoneum. D. Elevated blood glucose levels.

B. Outflow of dialysis solution is cloudy.

A client is scheduled to start taking corticosteroids after receiving a kidney transplant. Which of the following side effects should the nurse teach the client to report? A. Dizziness with position change. B. Pain in the hips, knees, and other joints. C. Changes in the character of the urine. D. Pain at the donor kidney site.

B. Pain in the hips, knees, and other joints.

The nurse develops a plan of care to prevent aspiration in a client who has become unconscious. Which nursing action will be most effective? A. Turn and reposition the client at least every 2 hours. B. Place the client in a side-lying position. C. Insert a nasogastric tube for feeding. D. Monitor the client for signs of respiratory distress.

B. Place the client in a side-lying position.

A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 525 mg/dL. The nurse should anticipate which of the following prescriptions from the provider? Select all that apply A. dexamethasone. B. Regular Insulin IV drip. C. 0.9% Sodium Chloride Bolus D. D5% and 0.45% sodium chloride. E. Glucophage.

B. Regular Insulin IV drip. C. 0.9% Sodium Chloride Bolus.

A client is admitted to the hospital. Arterial blood gas (ABG) results are: pH 7.38 PaCO2 58 mm Hg HCO3 39 mm Hg PaO2 88 mm Hg How would the nurse interpret these results? A. Respiratory alkalosis, fully compensated B. Respiratory acidosis, fully compensated C. Metabolic acidosis, partially compensated D. Metabolic acidosis, uncompensated

B. Respiratory acidosis, fully compensated

A client is admitted to the hospital. Arterial blood gas (ABG) results are: pH 7.30 PaCO2 51 mm Hg HCO3 25 PaO2 88 mm Hg How would the nurse interpret these results? A. Metabolic acidosis, compensated B. Respiratory acidosis, uncompensated C. Respiratory acidosis, compensated D. Respiratory alkalosis, uncompensated

B. Respiratory acidosis, uncompensated

The nurse administered sodium polystyrene sulfonate (Kayexalate) to a client with renal failure. Which change indicates the treatment has not had the desired effect? A. Serum calcium increases from 5.0 to 7.5 mg/dL. B. Serum potassium increases from 5.8 to 6 mEq/L. C. Urinary output increases from 15 to 50 mL/hr. D. Apical pulse decreases from 125 to 100 beats/min.

B. Serum potassium increases from 5.8 to 6 mEq/L.

A nurse instructs a hospitalized client in a low-cholesterol diet. The client indicates understanding of this diet by choosing which of the following from the dietary menu? A. Fried chicken, green beans, and skim milk. B. Spaghetti pasta with tomato sauce, salad, and coffee. C. Meatballs, green beans, and coffee. D. Hamburger, salad, and milkshake.

B. Spaghetti pasta with tomato sauce, salad, and coffee.

A charge nurse observes a new nurse performing all of these actions when providing care to a client with an arteriovenous (AV) graft. Which of the actions would require the charge nurse to intervene? A. Measuring the blood pressure in the unaffected arm. B. Starting an IV in the arm with the AV graft. C. Palpating the AV graft. D. Auscultating the graft for a bruit

B. Starting an IV in the arm with the AV graft.

A patient has a chest tube for treatment of a pneumothorax in the left lung. Which finding during your assessment requires immediate nursing intervention? A. The patient complains of tenderness at the chest tube insertion site. B. The patient has slight tracheal deviation to the right side. C. The water seal chamber fluctuates while the patient inhales and exhales. D. The water seal chamber has intermittent bubbling.

B. The patient has slight tracheal deviation to the right side.

A client has been diagnosed with a poorly differentiated colon cancer and asks the nurse to explain to what the term "poorly differentiated" means. Which statement by the nurse is most accurate? "Poorly differentiated cells... A. are tumor suppressor genes." B. are normal cells that regress to immature, nonfunctioning cells." C. are cells that perform a specific function within the body." D. are fetal cells that will mature into highly specialized cells".

B. are normal cells that regress to immature, nonfunctioning cells."

The nurse is developing a plan of care for a client experiencing Stage 5 chronic kidney disease. Which goal should the nurse include in the plan of care? The client will... A. sign up to receive hospice care B. begin dialysis treatment. C. verbalize understanding of the need to make high potassium food choices. D. demonstrate the ability to independently perform hemodialysis in the home.

B. begin dialysis treatment.

A client diagnosed with malignant melanoma will begin the biologic therapy, Interleukin-2 (IL-2). Which statement describing the action of IL-2 should the nurse include in the client's teaching plan? "IL-2 works by... A. preventing the bone marrow depression of the other chemo drugs." B. enhancing your immunological response to tumor cells." C. stimulating the malignant cells into the resting phase." D. selectively altering the DNA of malignant cells."

B. enhancing your immunological response to tumor cells."

A client with chronic kidney disease brings all home medications to the clinic to be reviewed by the nurse. Which medication being used by the patient indicates that further patient teaching is required? A. acetaminophen (Tylenol) 650 mg every 6 hr prn fever B. ibuprofen (Advil) 800 mg QID C. ferrous sulfate (Iron) 325 mg PO every day D. calcium acetate (PhosLo) 667 mg with meals

B. ibuprofen (Advil) 800 mg QID

A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care? A. "Hospice care services are available to patients who are terminally ill regardless of their life expectancy." B. "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care." C. "I should expect the hospice team to help me manage my dyspnea." D. "I will have to be admitted to a long-term care facility in order to receive hospice care."

C. "I should expect the hospice team to help me manage my dyspnea."

A client scheduled for a partial thyroidectomy asks the nurse why she is being given an iodine preparation before surgery. Which is the nurse's best response? A. "Iodine will help make the internal surgical environment sterile." B. "It is given to stimulate the storage of excess thyroid hormones." C. "It will prevent excessive bleeding during surgery." D. "This will replace the hormones you will lose after your operation."

C. "It will prevent excessive bleeding during surgery."

The nurse plans care for a client with cervical cancer receiving brachytherapy. Which of these statements would be appropriate for the nurse to say to the nursing assistant assigned to this client? A. "Radioactive precautions are needed only for the client's urine and body secretions." B. "The client's source of radioactivity is low and is only a threat to small children." C. "The client is a source of radioactivity." D. "Radioactive precautions do not need to be used on this client."

C. "The client is a source of radioactivity."

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? A. Auscultate the lungs to detect abnormal breath sounds. B. Encourage the client to cough and deep breathe. C. Elevate the head of the bed 30 to 45 degrees. D. Contact the physician.

C. Elevate the head of the bed 30 to 45 degrees.

A family member of a client with a brain tumor states that he is distraught and feeling guilty for not encouraging the client to seek medical evaluation earlier. Which of these responses would be most appropriate for the nurse to make? A. "It is true that brain tumors are easily recognizable." B. "There are no symptoms of a brain tumor." C. "The symptoms of a brain tumor may be easily attributed to another cause." D. "Brain tumors are never detected until very late in their course."

C. "The symptoms of a brain tumor may be easily attributed to another cause."

A client is diagnosed with breast cancer that is classified as T1, N1, M0. The client asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate? A. "The cancer has spread to other organs of the body." B. "The physicians cannot determine the original site of the breast cancer." C. "There is cancer present in regional lymph nodes." D. "The cancer cells look like normal breast cells."

C. "There is cancer present in regional lymph nodes."

Based on the glomerular filtration rate (GFR), which of the following client's medical treatment plan would include preparing for hemodialysis? A client whose GFR was: A. 95 mL/min B. 76 mL/min C. 17 mL/min D. 42 mL/min

C. 17 mL/min

Which of these findings identified in a client in the oliguric phase of acute kidney injury should a nurse report to a physician? A. Sodium level of 135 mEq/dL. B. Specific gravity of 1.025. C. 4 + edema present in the feet, and legs. D. Urine output of 500 ml/24 hr.

C. 4 + edema present in the feet, and legs.

A nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse should identify which of the following findings as an indication that the medication is effective? A. A decrease in blood sugar B. A decrease in specific gravity C. A decrease in urine output D. A decrease in blood pressure

C. A decrease in urine output

A client has been admitted to the hospital with a diagnosis of Pheochromocytoma. What assessment technique should the nurse avoid? A. Pupillary reaction to light B. Stand for baseline weight C. Abdominal palpation D. Extremity reflex checks

C. Abdominal palpation

A nurse is caring for a client with type 2 diabetes mellitus. Which action would the nurse teach the client, and/or client's family, to perform in order to manage the client's symptoms of hypoglycemia? A. Eliminate the evening dose of NPH insulin if the client is exercising. B. Carry rapid-acting glucose to treat hyperglycemia quickly. C. Administer glucagon if client becomes unresponsive due to hypoglycemia. D. Check the urine for acetone at least once a day.

C. Administer glucagon if client becomes unresponsive due to hypoglycemia.

The client has arterial blood gas values of pH 7.38, PaCO2 40, HCO3 22, PaO2 55. Which intervention should the nurse implement? A. Assess the client's respiratory status. B. Encourage the client to take deep breaths. C. Administer oxygen. D. Administer intravenous sodium bicarbonate.

C. Administer oxygen.

A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which of the following should the nurse include in client teaching? A. Immobilize the right arm. B. Place ice on the area after each treatment. C. Apply deodorant only under the left arm. D. Use a heating pad under the right arm.

C. Apply deodorant only under the left arm.

A client is admitted to the emergency room with headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. Which should the nurse do first? A. Maintain body temperature. B. Start an IV of 0.9% NS at 50 mL/hr. C. Apply high-dose oxygen via face mask. D. Obtain a psychiatric referral.

C. Apply high-dose oxygen via face mask.

A client with a hemothorax receives a chest tube attached to an Atrium chest drainage system. The nurse notices that the fluid in the water seal chamber is bubbling vigorously. Which of the following actions should the nurse perform? A. Ensure that the tubing is free of kinks. B. Apply stronger wall suction. C. Assess for an air leak in the system. D. Add more water to the water seal chamber.

C. Assess for an air leak in the system.

The LPN reports to the nurse that a postoperative client has become increasingly confused and has been unable to perform incentive spirometer for the past 6 hours. The client is scheduled for discharge and has not yet learned to perform wound care. What is the priority nursing action? A. Schedule time to teach wound care to a family member. B. Assess the client's ability to perform incentive spirometer every 2 hours. C. Assess the client's breath sounds and oxygen saturation. D. Establish a plan to re-orient the client at frequent intervals.

C. Assess the client's breath sounds and oxygen saturation.

The nurse is teaching a client who has developed peripheral neuropathy about foot care. Which instruction should the nurse include in the teaching plan? A. Use a heating pad for sore feet. B. Inspect your feet for injury once a month. C. Avoid going barefoot. D. Buy shoes a half size larger.

C. Avoid going barefoot.

The nurse is teaching a client who has a chronic kidney disease about the process of continuous ambulatory peritoneal dialysis (CAPD). Which of the following information should the nurse include in the teaching? A. CAPD is a dialysis treatment for clients who have had abdominal surgery. B. CAPD filters the clients blood through and artificial device called a dialyzer. C. CAPD requires fewer dietary and fluid restrictions than hemodialysis D. CAPD requires a rigid schedule of exchange times.

C. CAPD requires fewer dietary and fluid restrictions than hemodialysis

A client arrives at the emergency room with acute dyspnea and a pulmonary embolism is suspected. Which diagnostic test does the nurse anticipate? A. Chest magnetic resonance imaging B. Arterial blood gas C. CT Angiogram of the chest. D. Chest xray

C. CT Angiogram of the chest.

A client is hospitalized with chronic kidney injury. Which data will be most useful to the nurse in evaluating kidney function? A. Blood urea nitrogen level. B. Daily weight. C. Creatinine level. D. Urine volume.

C. Creatine level

When assessing a client for toxicities associated with Aminoglycoside therapy, the nurse should include evaluation of which of the following? (Choose all that apply) A. Vision tests B. Troponin levels C. Creatinine levels D. Amylase levels E. Hearing tests

C. Creatinine levels E. Hearing tests

A client who is receiving hemodialysis is experiencing muscle cramps. Operating on standing protocols, which of the following interventions should the nurse perform? A. Administer hydromorphone (Dilaudid) 0.5 mg IV push. B. Stop the dialysis treatment. C. Decrease the ultrafiltration rate and administer IV fluids. D. Administer oxygen 2L by nasal cannula.

C. Decrease the ultrafiltration rate and administer IV fluids.

A nurse is caring for a client following his first hemodialysis treatment. The client reports a headache, nausea, and restlessness. The nurse should identify these findings as manifestations of which of the following complications? A. Sepsis B. Peritonitis C. Dialysis disequilibrium D. Air embolism

C. Dialysis disequilibrium

During assessment of a client with a 10 year history of diabetes, the nurse notes that the client has decreased tactile sensation in both feet. Which action does the nurse take first? A. Assess sensory perception in the client's hands. B. Notify the physician. C. Examine the client's feet for signs of injury. D. Document the finding in the client's medical record.

C. Examine the client's feet for signs of injury.

A client with chronic renal failure is receiving epoetin alfa (Epogen, Procrit). Which lab result would indicate a therapeutic effect of the medication? A. WBC 6000 cells/mm 3. B. Creatinine 1.2 mg/dL C. Hemoglobin 13.5 g/dL D. Platelet count of 400,000 cells/mm 3C.

C. Hemoglobin 13.5 g/dL

Twenty days following a kidney transplant, the patient develops a temperature of 102.2 F, pain at the transplant site and oliguria. Which of the following post kidney transplant complications does the nurse suspect is present? A. Development of chronic rejection of the kidney with eventual failure of kidney. B. An infection of the kidney, which can be treated with intravenous antibiotics. C. Hyperacute rejection, which will necessitate the removal of the transplanted kidney. D. Acute rejection, which is not uncommon and usually reversible.

C. Hyperacute rejection, which will necessitate the removal of the transplanted kidney.

A client has metabolic alkalosis. What is the priority intervention for the nurse? A. Teach the client preventive measures. B. Administer bicarbonate intravenously. C. Initiate safety precautions. D. Administer insulin intravenously.

C. Initiate safety precautions.

A nurse is admitting a client with a diagnosis of myxedema to the hospital. The nurse performs which of the following to provide data related to this diagnosis? A. Palpates the adrenal glands B. Percusses the thyroid gland C. Inspect facial features D. Auscultates lung sounds

C. Inspect facial features

A nurse is developing an education program about skin cancer for a community center. Which of the following instructions should the nurse plan to include? A. Avoid the sun after 3 p.m. B. Limit tanning bed use. C. Keep a body map of skin lesions. D. Examine your body every 2 months for lesions.

C. Keep a body map of skin lesions.

A nurse is assessing a client to identify risk factors for disease. Which of the following findings is a risk factor for metabolic syndrome? A. Diagnosis of COPD B. Being an active runner. C. Large waist circumference D. Hyperglycemia E. Hypotension

C. Large waist circumference, D. Hyperglycemia

An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. On admission which of the following should the nurse assess first? A. Urine output B. Heart rate C. Lung sounds D. Serum Potassium level

C. Lung sounds

A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest where there was an impact on the steering wheel. Which goal will the nurse focus on? A. Ensure adequate circulating volume is maintained. B. Reduce the client's anxiety. C. Maintain adequate oxygenation. D. Decrease chest pain.

C. Maintain adequate oxygenation.

A nurse is reviewing the arterial blood gas values for a client. pH 7.52 PaCO2 48 mm Hg HCO3 is 32 mEq/L. The nurse should recognize that these findings indicate which of the following acid base balances? A. Metabolic alkalosis, uncompensated B. Metabolic acidosis, uncompensated C. Metabolic alkalosis, partially compensated D. Metabolic alkalosis, fully compensated

C. Metabolic alkalosis, partially compensated

A nurse is developing a plan of care for a client with diabetic ketoacidosis (DKA). The nurse includes which intervention in the plan? A. Assess for fluid overload. B. Limit family visitation time. C. Monitor potassium levels. D. Measure level of ketones in urine.

C. Monitor potassium levels.

A nurse is caring for a client with a pulmonary emboli who is receiving heparin intravenously (IV). The nurse plans to increase the heparin administration rate per the facility's heparin protocol. Which of the following nursing actions has the highest priority? A. Ensure aPTT is drawn 24 hours after rate increase. B. Educate the client on the reason the heparin rate is being increased. C. Monitor the client more frequently for evidence of bleeding. D. Check the expiration date on the heparin infusion bag.

C. Monitor the client more frequently for evidence of bleeding.

Doxorubicin (Adriamycin) is prescribed for a female client with breast cancer. The client is distressed about hair loss. Which instruction should the nurse include in the client education? A. Limit social contact until hair regrows. B. Wash and massage the scalp daily to stimulate hair growth. C. Obtain a wig before the hair loss begins. D. Hair loss is temporary and will quickly grow back to its original appearance.

C. Obtain a wig before the hair loss begins.

A nurse is giving the nursing assistant report on the patients that they have both been assigned to for the day. Which of the following tasks would be appropriate for the nurse to delegate to the nursing assistant? A. Provide peritoneal dialysis instructions to a patient with chronic kidney injury. B. Calculate the amount of fluid to be replaced for a patient with chronic kidney disease C. Obtain vital signs on a client who has just returned from a renal biopsy. D. Provide a client with education regarding an intravenous pyelogram.

C. Obtain vital signs on a client who has just returned from a renal biopsy.

A client with Cushing's disease has the following vital signs: Vital Signs Heart rate: 99 beats/minute Respiratory rate: 26/minute Blood pressure: 156/88 Oral temperature: 101 0F Which vital sign would be of most concern for a patient with Cushing's disease? A. Blood pressure B. Respiratory rate C. Oral temperature D. Heart rate

C. Oral temperature

A nurse is teaching a client who has a new diagnosis of hyperparathyroidism. The nurse should include in the teaching that the client is at risk for which of the following complications? A. Dysphagia B. Fluid Retention C. Pathologic Fractures D. Impaired skin integrity

C. Pathologic Fractures

The nurse is preparing to assist with the removal of a chest tube. Which item will the nurse have available at the bedside? A. ABD pad. B. Bandaid. C. Petroleum gauze. D. Steri-strips.

C. Petroleum gauze.

A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take? A. Check the client's blood pressure every 8 hr. B. Turn the client ever 4 hr. C. Place the client on aspiration precautions. D. Initiate measures to cool the client.

C. Place the client on aspiration precautions.

As survivors near the end of their initial treatment, how can the oncology team help them transition to completing therapy and entering into the extended stage of survival? A. Encourage the survivor to try to forget the past painful months and get on with life once therapy is completed. B. Have a party or ceremony to celebrate the end of treatment. C. Provide teaching on the follow-up plan so the client will understand what to expect after the initial treatment is completed. D. Discuss the risks of recurrence with the family so that the survivor does not worry.

C. Provide teaching on the follow-up plan so the client will understand what to expect after the initial treatment is completed.

Which assessment finding should the nurse expect when a patient with acute kidney injury has an arterial blood pH of 7.28? A. Hot, flushed face and neck B. Dry mucous membranes C. Rapid, deep respirations D. Weak peripheral pulses

C. Rapid, deep respirations

Which information should a nurse provide to a client who is taking sodium polystyrene sulfonate (Kayexalate)? A. This medication will increase the acidity of gastric juices. B. Take the medication with meals. C. This medication may cause diarrhea. D. Take the medication on an empty stomach.

C. This medication may cause diarrhea.

The nurse is preparing a community presentation on oral cancer. Which of the following is a primary risk factor for oral cancer that the nurse should include in the presentation? A. Lack of regular teeth cleaning by a dentist. B. Frequent use of mouthwash. C. Use of alcohol. D. Lack of vitamin B12.

C. Use of alcohol.

A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be A. dyspnea. B. infertility. C. dysphagia. D. diarrhea.

C. dysphagia.

The nurse counsels a woman who has a BRCA 1 gene mutation. Which explanation would be most appropriate for the nurse to give to the client regarding the client's risk for developing breast cancer during her lifetime? "Your risk for developing breast cancer during your lifetime is... A. none; this gene has a protective effect." B. lower than the general population." C. higher than the general population." D. same as the general population."

C. higher than the general population."

A client with acute kidney injury is scheduled for an intravenous pyelogram (IVP) in the outpatient setting. Which medication should the nurse instruct the client to hold 48 hours prior to the IVP? A. lisinopril (Prinivil) B. ergocalciferol (Vitamin D) C. metformin (Glucophage) D. glipizide (Glucotrol)

C. metformin (Glucophage)

The nurse teaches a client who is scheduled for a breast needle biopsy about the procedure. Which statement, if made by the client, indicates that teaching was effective? A. "I am so glad that the biopsy will remove the cancer from my breast." B. "The biopsy will determine how much longer I have to live." C. "We will know if the cancer has spread to other organs after we get the biopsy results." D. "The biopsy will help decide the treatment for my breast cancer."

D. "The biopsy will help decide the treatment for my breast cancer."

The charge nurse is assigning a room to a client who will undergo implantation of a temporary internal radiation source. Which of the following rooms should the nurse ask the admission staff to assign to the client? A. A semiprivate room between two isolation rooms. B. A single room near the nurse's station. C. A semiprivate room near the nurse's station. D. A single room at the distant end of the hall.

D. A single room at the distant end of the hall.

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are below: pH 7.50 PaCO2 29 mm Hg HCO3 20 mEq/L PaO2 60 mm Hg SpO2 86%. Which of the following is the priority nursing intervention? A. Assess for indications of pulmonary embolism. B. Prepare to administer a sedative. C. Prepare for mechanical ventilation. D. Administer oxygen via face mask.

D. Administer oxygen via face mask.

Which intervention is appropriate for a nurse include in the care plan for a client with hyperparathyroidism? A. Fluid restriction 1000 mL / day. B. Consume 3-5 dairy products a day. C. Use a soft bristled toothbrush for brushing teeth. D. Ambulate in the hall for 15 minutes three times a day.

D. Ambulate in the hall for 15 minutes three times a day.

A client who has been receiving hemodialysis treatments 3 times a week for the past year is admitted to the hospital. The client receives hemodialysis through an arteriovenous (AV) fistula in the right arm. Which intervention is included in this client's daily care? A. Assess the AV fistula for a blood return. B. Keep the AV fistula site wrapped in gauze. C. Take the blood pressure in the right arm. D. Assess the AV fistula for a bruit and thrill.

D. Assess the AV fistula for a bruit and thrill.

The nurse prepares to develop a diabetic teaching plan for a client. To meet the clients' needs, the nurse should take which action first? A. Discuss the focus of the teaching plan with the health care team. B. Instruct the client on the various types of insulins. C. Provide the client with specific recipes to use for meal planning. D. Assess the client's ability to administer their own medication.

D. Assess the client's ability to administer their own medication.

A client being seen in the emergency room is being evaluated for possible pulmonary embolus. The nurse preparing the client for a Ventilation-Perfusion scan (V/Q) scan plans to: A. Institute radioactive precautions post V/Q scan. B. Determine if the client has any metallic implants. C. Ask the client about the time of last food intake. D. Assess the clients ability to lay flat.

D. Assess the clients ability to lay flat.

A patient receiving peritoneal dialysis using 1.5 L of dialysate per exchange has an outflow of 1000 ml. Which action should the nurse perform? A. Administer sodium polystyrene sulfonate (Kayexalate) to the patient. B. Infuse an additional 500 ml of dialysate. C. Notify the physician about the outflow problem. D. Assist the patient to change their body position.

D. Assist the patient to change their body position.

A nurse is preparing a client for a kidney biopsy. Which of the following client conditions should the nurse identify as a contraindication for this diagnostic test? A. Flank pain B. Urinary retention C. Elevated creatinine D. Bleeding tendencies

D. Bleeding tendencies

A client admitted with DKA has been started on an insulin drip. The nurse will change IV fluids to a dextrose solution when: A. Patient is becomes alert. B. Insulin rate has stabilized. C. Potassium levels have stabilized. D. Blood Glucose is below 200 mg/dl

D. Blood Glucose is below 200 mg/dl

The nurse is caring for a client who just had a thoracentesis performed. Which assessment findings would the nurse expect? (Select all that apply) A. Moderate amount of bloody drainage on the dressing. B. SpO2 level is 10% below previous. C. Radial pulses are bounding. D. Blood pressure is 18 mm/hg below baseline. E. The client complains of a nagging cough.

D. Blood pressure is 18 mm/hg below baseline. E. The client complains of a nagging cough.

A nurse is caring for a client whose laboratory results show potassium level of 5.8 mEq/L. When assessing the client, the nurse should be alert for which occurrence? A. Constipation B. Chvostek's sign C. Decreased clotting time D. Cardiac arrhythmias

D. Cardiac arrhythmias

A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care? A. Check Blood Glucose every hour B. Educate the patient on the need for a fluid restriction. C. Administer a furosemide D. Check urine specific gravity

D. Check urine specific gravity

A nurse is assessing a client who has hypoparathyroidism. Which of the following findings should the nurse expect? A. Negative Chvostek's sign B. Client report of anorexia C. Flaccid muscles D. Client report of numbness in his hands

D. Client report of numbness in his hands

A client with renal failure returns from surgery for placement of an arteriovenous (AV) fistula in the right arm. Which of the following instructions should the nurse give to the unlicensed assistive personnel assigned to take the client's vital signs? A. Auscultate the AV fistula for a bruit. B. Elevate the left arm on 2 pillows. C. Monitor intake and output. D. Do not take blood pressures in the right arm.

D. Do not take blood pressures in the right arm.

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. Administer an expectorant B. Perform range-of-motion exercises C. Place suction equipment at the bedside D. Encourage the use of an incentive spirometer

D. Encourage the use of an incentive spirometer

A client is scheduled for a bronchoscopy. The nurse plans to implement which action? A. Ask the client about allergies to contrast dye B. Administer preprocedure antibiotics prophylactically C. Restrict the diet to clear liquids on the day of the test D. Ensure informed consent has been obtained before the procedure

D. Ensure informed consent has been obtained before the procedure

A client with cancer-related pain obtained adequate pain relief with IV morphine while hospitalized. Upon discharge to home he was switched to oral morphine and kept on the same dose. After being home 24 hours, he reports his pain as an 8 on a 10-point scale and wants the IV morphine. Which of the following represents the most likely explanation for the client's reports of inadequate pain control? A. He is addicted to the IV morphine. B. He is going through withdrawal from the IV opioid. C. He is physically dependent on the IV morphine. D. He is under medicated on the oral opioid.

D. He is under medicated on the oral opioid.

The nurse is planning postoperative care for a patient who is being admitted to the surgical unit from the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included? A. Palpate extremities for edema. B. Monitor continuous pulse oximetry for 24 hours. C. Check hematocrit every 2 hours for 8 hours. D. Measure urine volume every hour.

D. Measure urine volume every hour.

How should a nurse interpret the following ABG results: pH 7.48 PaCO2 38 mm Hg HCO3 29 mEq/L PaO2 100 mm Hg A. Metabolic Acidosis, uncompensated B. Metabolic Acidosis, compensated C. Metabolic Alkalosis, partially compensated D. Metabolic Alkalosis, uncompensated

D. Metabolic Alkalosis, uncompensated

A nurse is developing a plan of care with a client who is scheduled to begin hemodialysis. Which of the following nursing actions should be included in the care plan? (Choose all that apply) A. Instruct client to drink 3 Liters of fluid every day. B. Instill 2L of dialysate fluid into peritoneum 4 times a day C. Give antihypertensive medication prior to dialysis. D. Monitor serum creatinine, BUN, and hemoglobin levels. E. Obtain weight and vital signs prior to dialysis.

D. Monitor serum creatinine, BUN, and hemoglobin levels. E. Obtain weight and vital signs prior to dialysis.

A client, diagnosed with a hemothorax, has a chest tube. Which assessment finding requires intervention by the nurse? A. Tidaling in the drainage tubing. B. Absence of bubbling in the water seal chamber. C. Bloody drainage in the collection chamber. D. Pain at the insertion site.

D. Pain at the insertion site.

A client with end-stage renal disease is receiving peritoneal dialysis. Which of the following clinical manifestations are signs of complications associated with an infection of the catheter exit site? (Select All That Apply) A. Cloudy outflow of dialysis solution B. Oliguria C. Bradycardia D. Redness at the site E. Drainage at the site.

D. Redness at the site E. Drainage at the site.

A patient who has been receiving hemodialysis for 1.5 years tells the nurse, "I really don't want to have dialysis. I am tired and ready to stop treatment." Which one of the following descriptions best explains the client's statement? A. The client is experiencing effects of pain medication and not thinking clearly. B. The client is experiencing a diminished cognitive level due to a buildup of toxins. C. The client is experiencing a normal response to fear associated with loss of control. D. The client would like to stop receiving hemodialysis.

D. The client would like to stop receiving hemodialysis.

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? A. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg B. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg C. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg D. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg

D. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg

Which of the following goals of care is appropriate for a client with sarcoidosis in the lungs? The client will... A. verbalize understanding of fluid restriction B. describe treatment to eliminate sarcoidosis C. maintain a heart rate between 70-80 beats/minute D. rest between activities of daily living

D. rest between activities of daily living

A client received IV contrast day and has now developed acute renal failure. The client asks the nurse why she has developed acute renal failure. Which of these statements would the nurse include in the explanation? "You experienced ... A. a decrease in the blood flow though the kidneys." B. a blood clot that formed in the kidneys." C. an obstruction of urine flow from the kidneys." D. structural damage to the kidneys resulting in decreased kidney tissue function."

D. structural damage to the kidneys resulting in decreased kidney tissue function."

Identify the characteristics of the proper disease process. Can use options more than once, and there may be unused options. HHS 1. 2. 3. DKA 1. 2. 3. Options: -Blood Glucose >250 -Blood Glucose >600 -Bicarb IV -Severe dehydration -Insulin IV -Acidosis -D5W IV -Calcium IV

HHS 1. Blood Glucose >600 2. Insulin IV 3. Severe dehydration DKA 1. Blood Glucose >600 2. Insulin IV 3. Acidosis