Final
The nurse is providing teaching for a client who was recently diagnosed with aortic stenosis. Which of the following information would be appropriate for the nurse to include in the teaching? a. "Taking a daily blood thinner reduces the risk of complications associated with this condition." b. "An episode of loss of consciousness might be an indication that this condition has worsened." c. "This condition is usually benign, and most people live their whole lives without symptoms." d. "It is important that people with this condition do at least 30 minutes of aerobic exercise daily."
"An episode of loss of consciousness might be an indication that this condition has worsened."
During a well-woman physical examination, a 43-yr-old client asks about her risk for breast cancer. Which question is most pertinent for the nurse to ask? a. "Is there a family history of fibrocystic breast changes?" b. "Have you ever had a breast injury?" c. "Do you currently smoke tobacco?" d. "At what age did you start having menstrual periods?"
"At what age did you start having menstrual periods?"
The nurse is caring for a client who reports seeing a reddish colored tint in the urine. Which of the following questions would be most appropriate for the nurse to ask? a. "Are you able to leave a sample of urine?" b. "Are you having any pain?" c. "Is there any sediment in your urine?" d. "Do you take prescribed anticoagulants?"
"Do you take prescribed anticoagulants?"
The nurse is conducting a functional assessment for an older adult client. The client reports to the nurse, "I often forget where I put my keys, but that is expected at my age." Which of the following is the most appropriate response by the nurse? a. "How often do you think you forget where items are located?" b. "Yes, short term memory loss does occur as you get older." c. "What do you do to remember where your keys are?" d. "I lose my keys all the time, as long as you find the keys it is not a problem."
"How often do you think you forget where items are located?"
The nurse admits a client to the hospital in Addisonian crisis. Which client statement supports the need to plan additional teaching? a. "I always double my dose of hydrocortisone on the days that I go for a long run." b. "I monitor my blood glucose carefully for abnormally low levels." c. "I had the flu earlier this week, so I couldn't take the hydrocortisone." d. "I frequently eat at restaurants, and my food has a lot of added salt."
"I had the flu earlier this week, so I couldn't take the hydrocortisone."
The nurse is providing pre-operative teaching regarding autologous blood transfusion to a 60-year old client in preparation for surgery. Which of the following statements by the client would indicate correct understanding of the teaching? a. "I do not think I can develop a reaction if I receive my old blood." b. "I need to donate blood for the transfusion 5 weeks before my surgery." c. "I cannot receive autologous transfusion since I am a Jehovah's Witness." d. "I cannot donate blood for autologous transfusion because of my age"
"I need to donate blood for the transfusion 5 weeks before my surgery."
The nurse determines that additional instruction is needed for a client with chronic syndrome of inappropriate antidiuretic hormone (SIADH) when the client makes which statement? a. "I should eat foods high in potassium because diuretics cause potassium loss." b. "I should weigh myself daily and report any sudden weight loss or gain." c. "I need to shop for foods low in sodium and avoid adding salt to food." d. "I need to limit my fluid intake to no more than 1 quart of liquids a day."
"I need to shop for foods low in sodium and avoid adding salt to food."
Which client statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I should take the iron with orange juice about an hour before eating." b. "I should increase my fluid and fiber intake while I am taking iron tablets." c. "I will take a stool softener if I feel constipated occasionally." d. "I will call my health care provider if my stools turn black."
"I will call my health care provider if my stools turn black."
The nurse is providing teaching to a client with polycythemia vera regarding prevention of complications. Which of the following statements by the client would indicate that more teaching is required? a. "I will limit the amount of red meat in my diet." b. "I will limit my fluid intake each day." c. "I should apply my support hose upon waking." d. "I should use an electric razor when shaving."
"I will limit my fluid intake each day."
The nurse has taught a client with newly diagnosed hyperthyroidism about newly prescribed radioactive iodine therapy. Which of the following statements made by the client would indicate teaching was effective? a. "Once I am finished with the therapy, my grandchildren can come to visit." b. "I will use a separate bathroom from my family." c. "It is normal to experience dry mouth during therapy." d. "It is ok to help out with preparing the meals at home."
"I will use a separate bathroom from my family."
The nurse provides discharge teaching for a client who has two fractured ribs from an automobile accident. Which statement, if made by the client, would indicate that teaching has been effective? a. "I will use the incentive spirometer every hour or two during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I am going to buy a rib binder to wear during the day." d. "I should plan on taking the pain pills only at bedtime, so I can sleep."
"I will use the incentive spirometer every hour or two during the day."
The nurse has provided teaching for clients taking prescribed medications to manage chronic heart failure. Which of the following statements by a client would indicate the need for additional teaching? a. "I have to get my blood potassium level checked since I take lanoxin." b. "To monitor for a side effect of carvedilol, I will check my pulse daily and call if it is below 60." c. "The effectiveness of isosorbide dinitrate might diminish after I take it for a long time." d. "If I develop a cough, I will not be concerned because enalapril causes that."
"If I develop a cough, I will not be concerned because enalapril causes that."
The nurse on the cardiac unit is talking with a client who was just diagnosed with myocarditis. Which of the following instructions is appropriate for the nurse to give the client? a. "Walk up and down the hallway as much as possible to make your heart stronger." b. "Drink at least 3 liters of water in 24 hours to help flush the virus from your body." c. "Take the prescribed lanoxin to prevent your potassium from getting too low." d. "Keep the head of the bed elevated when you are in bed to reduce your heart's workload."
"Keep the head of the bed elevated when you are in bed to reduce your heart's workload."
The nurse is teaching a client who has hypothyroidism about newly prescribed levothyroxine. Which of the following statements should the nurse include in the teaching? a. "It is normal to experience diarrhea when taking this medication." b. "Take this medication on an empty stomach with a full glass of water." c. "This medication works best when taken before bedtime." d. "Your dose will be increased if you experience palpitations."
"Take this medication on an empty stomach with a full glass of water."
The nurse has attended a staff in-service about temporary pacemakers. Which of the following statements by the nurse demonstrates a proper understanding about the use of temporary pacemakers? a. "Temporary pacing defibrillates a client who has pulseless ventricular tachycardia." b. "Temporary pacemaker leads are attached to the epicardium during open-heart surgery." c. "Transcutaneous temporary pacing is less painful than epicardial temporary pacing." d. "A client who has atrial fibrillation with rapid ventricular response requires a temporary pacemaker."
"Temporary pacemaker leads are attached to the epicardium during open-heart surgery."
The nurse is planning an education conference at the local health clinic about hepatitis disease prevention and health promotion. Which of the following information should the nurse include in the conference? Select all that apply. a. "Using multidose vials of prescribed medication is encouraged whenever possible in the client care setting." b. "The community should be educated regarding safe practices for preparing and dispensing food." Vaccines are required for international travelers coming into the United States (US)." c. "Vaccinations should be encouraged to interrupt community-wide outbreaks and people at risk for infection." d. "Clients should be encouraged to avoid high-risk behaviors such as intravenous (IV) drug use and unprotected sex."
"The community should be educated regarding safe practices for preparing and dispensing food." "Vaccinations should be encouraged to interrupt community-wide outbreaks and people at risk for infection." "Clients should be encouraged to avoid high-risk behaviors such as intravenous (IV) drug use and unprotected sex."
The nurse is teaching a client who is postoperative abdominal surgery the purpose of the incentive spirometer. Which of the following statements by the nurse would indicate a correct understanding of the procedure? a. "The spirometer can help you cough out the secretions in your lungs." b. "The spirometer can prevent formation of blood clots in your lungs." c. "The spirometer can prevent the development of fever after surgery." d. "The spirometer can help the expansion of your lungs after surgery."
"The spirometer can help the expansion of your lungs after surgery."
The nurse in the ambulatory surgical center is assessing a client scheduled for surgery requiring general anesthesia. The client states, "I ate a light breakfast about 2 hours ago." Which of the following statements by the nurse would be appropriate? a. "You may experience more nausea than usually expected after the surgery." b. "We will have to wait another two hours to do your surgery." c. "We will give you medication to prevent you from vomiting during the surgery." d. "There is a possibility that your surgery will be rescheduled."
"There is a possibility that your surgery will be rescheduled."
The nurse is teaching a client with mild-to-moderate chronic heart failure about self-care. Which of the following information would be appropriate for the nurse to give to the client? a. "Encourage your spouse to get a flu shot, but do not get a flu shot yourself." b. "Perform your activities of daily living, but do not do any exercise." c. "Measure the amount of fluid you drink and limit it to 1 liter per day." d. "Weigh yourself each morning and call the physician's office if you gain 5 lbs. within a week."
"Weigh yourself each morning and call the physician's office if you gain 5 lbs. within a week."
The evening shift nurse received report that a signed consent is needed before the client goes to surgery in the morning. The nurse was not present when the surgeon explained the procedure to the client. Which of the following statements by the nurse would be most appropriate before asking the client to sign the consent form? a. "You have the right to change your mind at any time." b. "What were you told about your surgical procedure?" c. "Do you have any questions about your surgery tomorrow?" d. "Your surgeon asked me to ensure that you sign the consent form."
"What were you told about your surgical procedure?"
The nurse is collecting the health history of a client who reports daytime drowsiness. Which of the following statements would indicate to the nurse that the client is experiencing restless leg syndrome? a. "When I lie down at night, I feel like I need to keep moving my legs." b. "My legs feel heavy in the morning." c. "If I keep my legs still, the crawling sensation goes away." d. "I noticed that the color of my toes often change color."
"When I lie down at night, I feel like I need to keep moving my legs."
The nurse is completing the health history interview with a client who reports experiencing pain in the left breast. Which of the following responses, by the nurse, would be most appropriate? a. "Do not worry about the pain; breast cancer is not painful." b. "Breast pain is almost always the result of benign breast disease." c. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." d. "When did you first notice the pain in your left breast?"
"When did you first notice the pain in your left breast?"
The nurse is teaching a client who is newly diagnosed with hyperparathyroidism about preventing complications. Which of the following statements should the nurse include in the teaching? a. "You should refrain from participating in contact sports, which could cause fractures." b. "If you notice an increase in fluid retention, then decrease your sodium intake." c. "Try to prevent any injury to your skin, as you may experience delayed wound healing." d. "Since you can have a lack of tooth enamel, you may need to see the dentist more frequently."
"You should refrain from participating in contact sports, which could cause fractures."
The nurse is teaching a client who has varicose veins about sclerotherapy. Which of the following information should the nurse include in the teaching? a. "General anesthesia is required for the procedure." b. "Bed rest is required for 24 hours after the procedure." c. "You must avoid wearing compression stockings before the procedure." d. "You will receive intravenous injections during the procedure."
"You will receive intravenous injections during the procedure."
The nurse is assessing four clients at the neighborhood clinic. Which of these clients should the nurse identify to be at risk for the development of iron-deficiency anemia? a. 50-year old male who is following a high-fat and high-protein diet b. 43-year old male who had gastric bypass surgery one year ago. c. 35-year old male recently diagnosed with chronic renal failure. d. 26-year old woman in her second trimester of pregnancy
26-year old woman in her second trimester of pregnancy
The nurse monitors a client in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. Subcutaneous emphysema at the insertion site b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. A large air leak in the water-seal chamber
400 mL of blood in the collection chamber
The nurse participating in a community health fair is assessing clients for pancreatic cancer risk factors. Which of the following clients have the highest risk in developing the disorder? a. 40-year old Asian American who has chronic pancreatitis b. 52-year old Caucasian who has type 2 diabetes mellitus c. 46-year old American Indian who has hypercholesterolemia d. 56-year old African American who smokes 5 cigarettes a day
56-year old African American who smokes 5 cigarettes a day
The nurse in a primary care office is implementing a protocol for evaluating heart failure risk. The nurse demonstrates competence by identifying which of the following clients as having the highest risk for heart failure? a. 60-year-old Caucasian man with type 2 diabetes mellitus b. 58-year-old African American man with blood pressure 148/86 mm Hg c. 62-year-old Asian woman with a history of acute pericarditis d. 44-year-old Hispanic woman with a body mass index of 32
58-year-old African American man with blood pressure 148/86 mm Hg
The emergency room nurse is caring for a client who has a sucking chest wound resulting from a gunshot wound. The client has a blood pressure of 100/60 mm/Hg, a weak pulse, and a respiratory rate of 40 breaths/min. Which of the following actions should be the priority for the nurse to take? a. Apply a three-sided, occlusive dressing over the wound b. Prepare the client for chest tube insertion c. Administer prescribed analgesic d. Position the client in semi-Fowler's position
Administer prescribed analgesic
An hour after a thoracotomy, a client complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? a. Assist the client with incentive spirometry. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Clamp the chest tube in two places.
Administer the prescribed morphine.
A client develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which action should the nurse take next? a. Give the scheduled dose of diltiazem (Cardizem). b. Have the client perform the Valsalva maneuver. c. Recheck the heart rhythm and BP in 5 minutes. d. Apply the transcutaneous pacemaker (TCP) pads.
Apply the transcutaneous pacemaker (TCP) pads.
A client is thrombocytopenic, their complete blood count (CBC) indicates this. Which action should the nurse include in the plan of care? Select all that apply a. Use electric razors. b. Encourage increased oral fluids. c. Check temperature orally. d. Avoid intramuscular injections. e. Increase intake of iron-rich foods.
Avoid intramuscular injections.
Which information about continuous bladder irrigation will the nurse teach to a client who is being admitted for a transurethral resection of the prostate (TURP)? a. Hydration and urine output are maintained by bladder irrigation. b. Bladder irrigation prevents obstruction of the catheter after surgery. c. Bladder irrigation decreases the risk of postoperative bleeding. d. Antibiotics are infused continuously through the bladder irrigation.
Bladder irrigation prevents obstruction of the catheter after surgery.
The nurse is assessing a client who has Parkinson's disease. Which of the following findings should the nurse expect with this client? a. Flaccid muscles b. Bradykinesia c. Dry skin d. Xerostomia
Bradykinesia
A client received nifedipine (Procardia) for his idiopathic pulmonary arterial hypertension (IPAH). Which assessment would best indicate to the nurse that the client's condition is improving? a. Client reports a decrease in exertional dyspnea. b. Blood pressure (BP) is less than 140/90 mm Hg. c. Client's chest x-ray indicates clear lung fields. d. Heart rate is between 60 and 100 beats/minute.
Client reports a decrease in exertional dyspnea
A client who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Adjust the dial on the wall regulator. d. Continue to monitor the collection device.
Continue to monitor the collection device.
The nurse is caring for a client with type 2 diabetes mellitus with nephropathy and chronic kidney disease (CKD). The nurse noted that the client's blood pressure is persistently high. Which of the following information should the nurse recognize as the reason the client's blood pressure is high? a. Decreased renal perfusion triggers the renin-angiotensin-aldosterone system b. Increased serum glucose increases aldosterone release causing water retention c. The angiotensin-converting enzyme is inhibited in type 2 diabetes d. Release of antidiuretic hormone is suppressed in type 2 diabetes
Decreased renal perfusion triggers the renin-angiotensin-aldosterone system
The nurse is assessing a client who has a magnesium level of 3.0 mEq/L. Which of the following findings should the nurse expect to observe? a. tachycardia b. increased urine output c. hypertension d. diminished deep tendon reflexes
Diminished deep tendon reflexes
The nurse is collecting a 24-hour urine specimen from a client. Which of the following interventions would demonstrate correct technique for collecting a 24-hour urine specimen? a. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container. b. Ask the client to urinate and pour the urine into a specimen container. c. Keep all voids in a container at room temperature for 24-hours. d. Discard the first voiding.
Discard the first voiding.
A client who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH). b. Prepare for platelet transfusion. c. Discontinue the heparin infusion. d. Administer prescribed warfarin (Coumadin).
Discontinue the heparin infusion.
The nurse is caring for a client who had the pituitary gland removed 24-hours ago and has developed a cerebrospinal fluid (CSF) leak. Which of the following actions should the nurse take? a. Elevate the head of the client's bed. b. Apply more packing to the client's dressing. c. Instruct the client to perform the Valsalva maneuver. d. Encourage the client to increase oral fluid intake.
Elevate the head of the client's bed.
The nurse is caring for a client who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Monitor for Trousseau's and Chvostek's signs. b. Maintain the client on bed rest. c. Auscultate lung sounds every 4 hours. d. Encourage fluid intake up to 4000 mL every day.
Encourage fluid intake up to 4000 mL every day.
The nurse is caring for a client who had a laparoscopic cholecystectomy 20 hours ago and is reporting bloating and shoulder pain. Which of the following would be the best action by the nurse? a. Administer prescribed pain medication. b. Encourage the client to ambulate frequently. c. Explain that the pain is most likely caused by positioning during surgery. d. Assess the client for embolus.
Encourage the client to ambulate frequently.
The nurse is caring for a newly admitted 25-year-old male who is in sickle cell crisis. Which of the following interventions should be of highest priority for this client? a. Administering pain medication prn b. Encouraging fluid intake of at least 200 mL/hour c. Placing the client in high Fowler's position d. Obtaining hourly blood pressure readings
Encouraging fluid intake of at least 200 mL/hour
A 37-yr-old female client is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Blood urea nitrogen (BUN) level c. Glomerular filtration rate (GFR) d. Creatinine level
Glomerular filtration rate (GFR)
The nurse assesses a client who has been hospitalized for 2 days. The client has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature of 100.1°F b. Serum sodium level of 138 mEq/L (138 mmol/L) c. Weight gain of 2 pounds (1 kg) over the admission weight d. Gradually decreasing level of consciousness (LOC)
Gradually decreasing level of consciousness (LOC)
The nurse is caring for a client who had an open reduction internal fixation 2 hours ago to correct a fractured hip. Which of the following assessment findings would require immediate follow-up? a. Pain rated 6 on a scale of 0-10 b. Hemovac drainage of 125 mL c. Poor nutritional status d. Absence of leg immobilizer
Hemovac drainage of 125 mL
The nurse is reviewing the biopsy results for a client admitted with unexplained weight loss. The nurse notes the pathology shows the presence of Reed-Sternberg cells. The nurse should understand the client is experiencing which of the following? a. Hodgkin's lymphoma b. Chronic myeloid leukemia c. Non-hodgkin's lymphoma d. Acute lymphocytic leukemia
Hodgkin's lymphoma
The nurse is reviewing the laboratory data for a client with renal failure and notes that the client is experiencing hyperphosphatemia. The nurse should assess the client for which of the following additional electrolyte imbalances? a. Hypokalemia b. Hypocalcemia c. Hypomagnesium d. Hyponatremia
Hypocalcemia
The nurse is assessing a client with a head injury who has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect to observe? a. Polydipsia b. Weight loss c. Hypernatremia d. Oliguria
Hyponatremia
The nurse is caring for a client with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should: a. assist the client with light weight bearing. b. apply heat to the knee. c. perform passive range of motion to the knee. d. immobilize the knee joint.
Immobolize the knee joint.
A nurse is assessing a client who has rotator cuff injury. Which of the following findings should the nurse expect to observe? a. Inability to maintain abduction of the arm at the joint. b. Difficulty performing circumduction of the joint c. Unable to shrug shoulders. d. Alteration in the contour of the joint.
Inability to maintain abduction of the arm at the joint.
The nurse is caring for a client who reports sudden onset of dyspnea and "feeling of doom." The nurse suspects the client is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? a. Initiate high-flow oxygen b. Initiate strict bedrest c. Administer prescribed morphine IV d. Administer prescribed heparin IV
Initiate high-flow oxygen
The nurse is transferring a client up to the chair, who has a pneumothorax and has a left pleural chest tube connected to dry suction drainage system. The nurse notes that during transfer, the chest tube disconnected from the drainage system. Which of the following actions should the nurse take? a. Insert the chest tube into bottle of sterile water b. Apply occlusive dressing to the end of the chest tube c. Connect chest tube to wall suction d. Clamp the chest tube
Insert the chest tube into bottle of sterile water
The nurse is performing a neurological assessment for a client with a head trauma. Which of the following actions by the nurse would assess the function of the client's cranial nerve III. a. Have client stand with eyes closed and touch their nose. b. Ask the client to shrug shoulders against passive resistance. c. Instruct the client to look up and down without moving their head. d. Observe the client's ability to smile and frown.
Instruct the client to look up and down without moving their head.
The nurse is preparing discharge teaching for a client diagnosed with cirrhosis. Which of the following information should the nurse include in the discharge teaching? a. Advice the client to avoid using bath oils when taking hot showers. b. Instruct the client to avoid garlic and spicy seasoning in food preparations. c. Instruct the client to use the knuckles to rub the skin during itching episodes. d. Advise the client that canned vegetables can be substituted for fresh ones.
Instruct the client to use the knuckles to rub the skin during itching episodes.
The nurse is providing care for a client with disseminated intravascular coagulation (DIC) who develops clinical manifestations of microvascular thrombosis. The nurse should assess the client for which of the following? a. ischemia b. hematuria c. petechiae d. hemoptysis
Ischemia.
The nurse is monitoring a client who is receiving a prescribed intravenous transfusion of packed red blood cells. Which of the following findings should indicate to the nurse the client is experiencing fluid volume overload? Select all that apply a. hypotension b. Jugular vein distention c. cold clammy skin d. Confusion e. Dyspnea
Jugular vein distention Confusion Dyspnea
Which assessment finding may indicate that a client is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation? a. Increased serum creatinine b. Postural hypotension c. Knee and hip joint pain d. Recurrent tachycardia
Knee and hip joint pain
The nurse is discussing with a client, who has a prescription for thyroid-stimulating hormone level, the purpose of the diagnostic test. The nurse should explain that the test does which of the following? a. Measures the function of the thyroid. b. Detects the amount of thyroid hormone circulating in the blood. c. Measures the rate of absorption of iodine by the thyroid gland. d. Detects if there is antithyroid antibodies in the blood.
Measures the function of the thyroid.
A client who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic alkalosis b. Respiratory acidosis c. Respiratory alkalosis d. Metabolic acidosis
Metabolic acidosis
The nurse is caring for a client with hepatic encephalopathy who has an arterial blood gas result as follows: pH 7.55, pO2 92 mm Hg, pCO2 52 mm Hg, HCO3- 35 mEq/L. The nurse should interpret the ABG as which of the following? a. Metabolic alkalosis b. Respiratory acidosis c. Respiratory alkalosis d. Metabolic acidosis
Metabolic alkalosis
The nurse is educating about which foods to avoid that are high in potassium to a client with renal failure who is receiving dialysis. Which of the following foods that are high in potassium chosen by the client would indicate to the nurse that teaching was effective? Select all that apply. a. White pasta b. Milk c. Cantaloupe d. Apple e. Mashed potatoes
Milk, potatoes, and cantaloupe
A client admitted with multiple myeloma, which action will the nurse include in the plan of care? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Limit weight bearing and ambulation. d. Assess lymph nodes for enlargement.
Monitor fluid intake and output
Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in client teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy
Need for follow-up appointments to screen for malignancy
The evening shift nurse is caring for a client who is scheduled for surgery. The client states "I once got a rash from wearing rubber gloves." Which of the following actions should the nurse take? a. Notify the operating room staff that the client has an allergy to sulfur-containing products. b. Notify the surgeon so that the surgery can be cancelled. c. No intervention is needed since the client will not be wearing gloves. d. Note in the medical record that the client has a latex allergy.
Note in the medical record that the client has a latex allergy.
A client with cor pulmonale and right-sided heart failure, receives prescribed therapies from the nurse. Which assessment could be used to evaluate the effectiveness of the therapies? a. Palpate for heaves or thrills over the heart. b. Auscultate for crackles in the lungs. c. Observe for distended neck veins. d. Monitor for elevated white blood cell count.
Observe for distended neck veins
The nurse is reviewing the laboratory results on a client diagnosed with liver cirrhosis and noted that the serum ammonia level is elevated. Which of the following interventions should the nurse implement based on the laboratory findings? a. Provide the client with an electric razor. b. Obtain a prescription for lactulose. c. Place the client on a low potassium diet. d. Monitor the client's activity level.
Obtain a prescription for lactulose
The nurse is checking the patency of the AV fistula for a client who had the fistula placed 3 days ago on the left arm as a vascular access for hemodialysis. Which of the following actions should the nurse take? a. Flush the vascular access with heparinized saline. b. Palpate the fistula to detect the presence of "thrill" c. Withdraw 5 mL of blood from the vascular access. d. Check the blood pressure on the affected arm.
Palpate the fistula to detect the presence of "thrill"
The emergency room nurse is assessing a client who sustained a blunt chest trauma in a motor vehicle accident and notes bruising over the chest and right flank. Which of the following findings observed by the nurse would best indicate the client is experiencing a flail chest? a. Subcutaneous emphysema b. Diminished breath sounds c. Paradoxical chest movement d. Tracheal shift towards the left
Paradoxical chest movement
A client with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this client would include information about which anticipated intervention? a. IV adenosine b. Emergency cardioversion c. Permanent pacemakers d. Anticoagulant therapy
Permanent pacemakers
The nurse is caring for a client being treated for autoimmune thrombocytopenic purpura. Which of the following findings should the nurse assess to determine efficacy of the treatment? a. Potassium levels b. Platelet count c. Partial prothrombin time (PTT) d. White blood cell count
Platelet count
The nurse is reviewing the laboratory data of a client with rheumatoid arthritis who is taking prescribed methotrexate. Which of the following results would indicate to the nurse the client is experiencing an adverse effect of the medication? a. Blood glucose of 125 d/L b. ALT of 30 U/L c. WBC of 10,000 mm3 d. Platelet count of 100 μL
Platelet count of 100 μL
The nurse is assessing a client who is post-operative 8 hours from a left pneumonectomy for lung cancer. Which of the following should the nurse expect to find? a. Pleural chest tubes attached to wall suction b. Sternal incision with dressing c. Diminished breath sounds bilaterally with auscultation d. Positioned on the unaffected side
Pleural chest tubes attached to wall suction
The nurse in the post-anesthesia care unit (PACU) is caring for a female client who had an abdominal cholecystectomy. The client states "I think I am going to vomit." Which of the following interventions should the nurse perform? a. Position the client in the lateral recumbent position. b. Tilt the client's head back and elevate the jaw. c. Administer beta-adrenergic drugs as prescribed. d. Increase the client's IV fluids
Position the client in the lateral recumbent position.
The nurse is caring for a client who is postoperative appendectomy who has a prescription to ambulate. Which of the following actions should the nurse take first before ambulating the client? a. Position the client on the side of the bed b. Provide the client with additional oral fluids c. Have the client do deep breathing exercises d. Encourage the client to stand up quickly to alleviate abdominal pain.
Position the client on the side of the bed
A client with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the client for the procedure? a. Start a peripheral IV line to administer sedatives. b. Remind the client not to eat or drink anything for 6 hours. c. Position the client sitting up on the side of the bed. d. Obtain a collection device to hold 3 liters of pleural fluid.
Position the client sitting up on the side of the bed.
The nurse is assessing a client in sickle cell crisis who reports pain in the hands and feet. The nurse notes a pulse oximetry reading of 91%. Which of the following prescribed interventions should the nurse implement first? a. Administer morphine 4 mg IV push b. Administer an intravenous fluid bolus c. Provide 2L of oxygen by nasal cannula d. Cover the client with warm blankets
Provide 2L of oxygen by nasal cannula
A client with a 42 pack-year history of cigarette smoking, which information about prevention of lung disease should the nurse include? a. Resources for support in smoking cessation b. Erlotinib (Tarceva) therapy to prevent tumor risk c. Computed tomography (CT) screening for cancer d. Reasons for annual sputum cytology testing
Resources for support in smoking cessation
The nurse is caring for a client who is experiencing a panic attack and notes the client's arterial blood gas (ABG) results are pH 7.50, CO2 27, HCO3 24. The nurse should interpret the results as which of the following? a. Metabolic acidosis b. Respiratory alkalosis c. Respiratory acidosis d. Metabolic alkalosis
Respiratory alkalosis
Which information obtained by the nurse assessing a client admitted with multiple myeloma is most important to report to the health care provider? a. Urine sample has Bence-Jones protein. b. Serum calcium level is 15 mg/dL. c. Client is complaining of severe back pain. d. Client reports no stool for 5 days.
Serum calcium level is 15 mg/dL.
When caring for a client with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the client's food tray? a. Grape juice b. Mixed green salad c. Skim milk d. Fried chicken breast
Skim milk
A client has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The client receives a regular diet tray b. Staff have turned off the lights in the client's room c. Staff have entered the client's room without a mask d. The bedrails on both sides of the bed are elevated
Staff have entered the client's room without a mask
A client who is diagnosed with a lung abscess, which intervention will the nurse include in the plan of care? a. Teach the client to avoid the use of over-the-counter expectorants. b. Teach about the need for prolonged antibiotic therapy after discharge from the hospital. c. Assist the client with chest physiotherapy and postural drainage. d.Notify the health care provider immediately about any bloody or foul-smelling sputum.
Teach about the need for prolonged antibiotic therapy after discharge from the hospital.
Which action will the nurse take when caring for a client with osteomalacia? a. Emphasize the importance of sunscreen use when outside b. Educate about the need for weight-bearing exercise c. Teach about the use of vitamin D supplements d. Discuss the use of medications such as bisphosphonates
Teach about the use of vitamin D supplements
Which assessment finding for a 33-yr-old female client admitted with Graves' disease requires the most rapid intervention by the nurse? a. Severe bilateral exophthalmos b. Heart rate 136 beats/min c. Blood pressure 166/100 mm Hg d. Temperature 103.8° F (40.4° C)
Temperature 103.8° F (40.4° C)
Which assessment finding of a 42-yr-old client who had a bilateral adrenalectomy requires the most rapid action by the nurse? a. The blood pressure (BP) is 88/50 mm Hg. b. The client reports 6/10 incisional pain. c. The blood glucose is 192 mg/dL. d. The lungs have bibasilar crackles.
The blood pressure (BP) is 88/50 mm Hg.
The nurse is developing the plan of care for a group of assigned clients. Which of the following clients should the nurse identify as having the highest risk for developing a pulmonary embolism? a. The client who had a heart catherization and is on bedrest. b. The client who had a left hip arthroplasty and is unable to bear weight. c. The client who had a laparoscopic appendectomy and is ambulating with assistance. d. The client who had a cataract extraction and has a prescription to avoid bending over.
The client who had a left hip arthroplasty and is unable to bear weight.
The nurse is developing the plan of care for a group of assigned clients with drainage tubes. Which of the following clients should the nurse identify as having a risk for hypokalemia? a. The client who has a tracheostomy tube connected to humidified oxygen. b. The client who has an indwelling urinary catheter to gravity drainage. c. The client who has a nasogastric tube to intermittent suction. d. The client who has a pleural chest tube to water seal.
The client who has a nasogastric tube to intermittent suction.
When assessing a 53-yr-old client with bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention? a. The client has a positive Kernig's sign b. The client exhibits nuchal rigidity c. The client's temperature is 101° F (38.3° C) d. The client's blood pressure is 88/42 mm Hg
The client's blood pressure is 88/42 mm Hg
The nurse is caring for a client who has a central venous access device (CVAD). Which action by the nurse is appropriate? a. Use the push-pause method to flush the CVAD after giving medications. b. Obtain an order from the health care provider to change CVAD dressing. c. Avoid using friction when cleaning around the CVAD insertion site. d. Position the client's face toward the CVAD during injection cap changes.
Use the push-pause method to flush the CVAD after giving medications.
The nurse is caring for a client diagnosed with alcoholic cirrhosis who is reporting tingling sensation in the hands and feet. The nurse recognizes that these symptoms are due to which vitamin deficiency? a. Vitamin D b. Vitamin B1 c. Vitamin A d. Vitamin C
Vitamin B1
The nurse is talking with a female client who states she found a painless lump in the right breast during her monthly self-examination. She says that she is afraid that she has cancer. The nurse should recognize that which of the following assessment findings would strongly suggest that the client's lump is cancerous? a. a mobile mass that is soft and easily delineated b. an inverted right nipple and mobile mass c. a non-mobile mass with irregular edge d. nonpalpable right axillary lymph nodes
a non-mobile mass with irregular edge
The nurse in an outpatient setting is talking with a client who has symptoms that the client suspects are caused by varicose veins. Which of the following questions should the nurse ask? a. "Do you notice if the aching in your legs improves if you lie down and prop them on pillows?" b. "Does wearing compression stockings make throbbing in your legs worse?" (WRONG) c. "Do you notice that your legs hurt more when you wake up than they do in the evening?" d. "Does the pain in your legs start a couple minutes after you start walking?"
a. "Do you notice if the aching in your legs improves if you lie down and prop them on pillows?"
A client asks the nurse why they are on two medications enoxaparin (Lovenox) and warfarin (Coumadin) for the diagnosis of deep vein thrombosis (DVT). Which response by the nurse is most accurate? a. "Enoxaparin will work right away, but warfarin takes several days to begin preventing clots." b. "Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming." (WRONG) c. "Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner." d. "Taking two blood thinners greatly reduces the risk for another clot to form."
a. "Enoxaparin will work right away, but warfarin takes several days to begin preventing clots."
The nurse on the cardiac unit has taught a client with chronic heart failure about a low-sodium diet. Which of the following statements by the client would require additional teaching by the nurse? a. "I will read labels and limit my total daily sodium intake to about 15 grams." b. "Using lemon juice instead of table salt to flavor food is good way to minimize sodium consumption." c. "Avoiding lunch meat and canned vegetables is recommended because they are often high-sodium." d. "I should consider a food high-sodium if it contains 400 mg of sodium or more per serving." (WRONG)
a. "I will read labels and limit my total daily sodium intake to about 15 grams."
The nurse is planning care for a client with hepatic cirrhosis who has ascites. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply. a. Measure the client's weight and abdominal girth daily. b. Teach the client the importance of a low sodium diet. c. Encourage the client to ambulate several times per day. d. Provide an electric razor and soft-bristled toothbrush during activities of daily living (ADL's). e. Monitor the client's serum ammonia, creatinine and electrolyte levels.
a. Measure the client's weight and abdominal girth daily. b. Teach the client the importance of a low sodium diet. d. Provide an electric razor and soft-bristled toothbrush during activities of daily living (ADL's). e. Monitor the client's serum ammonia, creatinine and electrolyte levels.
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a client with acute pancreatitis? a. Muscle twitching and finger numbness b. Nausea and vomiting c. Hypoactive bowel sounds d. Upper abdominal tenderness and guarding (WRONG)
a. Muscle twitching and finger numbness
The nurse is planning care for a client who was admitted with the Hepatitis B virus (HBV). Which of the following precautions should the nurse include in the client's plan of care? a. standard b. contact c. droplet (WRONG) d. airborne
a. standard
The nurse in a cardiology practice is talking with a client with chronic heart failure who has been implementing self-care measures at home. The nurse should follow up if the client reports which of the following? a. taking over-the-counter cough medicine to help control night-time cough b. counting the pulse for a minute before taking a prescribed beta-blocker c. walking up and down the neighborhood block twice a day d. measuring body weight each morning with clothes off (WRONG)
a. taking over-the-counter cough medicine to help control night-time cough
The nurse is assessing a client with a spinal cord injury following a skiing accident. Which of the following techniques should the nurse use to test the function of the spinothalamic tract? a. ask the client to push the lower extremity against an opposing force b. apply light pressure from a sharp object to the client's lower extremity c. strike the client's patella tendon with a hammer d. instruct the client to perform straight leg raise
apply light pressure from a sharp object to the client's lower extremity
To assess the client with pericarditis for evidence of a pericardial friction rub, the nurse should: a. auscultate with the diaphragm of the stethoscope on the lower left sternal border. b. feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction. c. ask the client to cough during auscultation to distinguish the sound from a pleural friction rub. d. listen for a rumbling, low-pitched, systolic murmur over the left anterior chest.
auscultate with the diaphragm of the stethoscope on the lower left sternal border.
The nurse has performed discharge teaching with a client with Hepatitis A virus (HAV). Which of the following statements by the client would indicate a correct understanding of the teaching? a. "After I receive the first dose of the Hepatitis A vaccine I will be protected from contracting HAV." (WRONG) b. "All of my family members should wash their hands frequently." c. "I will avoid eating fresh fruits and vegetables." d. "As long as I use a condom during intercourse I will not need to worry about transmitting HAV."
b. "All of my family members should wash their hands frequently."
The nurse is caring for a client who was admitted to the hospital with an acutely inflamed gallbladder and right upper quadrant pain. The client states to the nurse, "I suddenly feel better. The pain was really bad early this morning but then it completely stopped by 9 am." Which of the following actions should the nurse take? a. Reassess the client in an hour. b. Contact the health care provider immediately. c. Check when the client last received pain medication. (WRONG) d. Change the client's diet from clear liquids to regular as tolerated.
b. Contact the health care provider immediately.
The nurse is developing a plan of care for a client diagnosed with acute pancreatitis who is reporting abdominal pain. Which of the following interventions should the nurse include in the plan of care? a. Encourage the client to ambulate frequently b. Provide a diet that is low in fat c. Check the client's blood sugar three to four times per day d. Encourage an increase in daily oral fluid intake (WRONG)
b. Provide a diet that is low in fat
A client whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable pulses. What action should the nurse take next? a. Perform synchronized cardioversion b. Start cardiopulmonary resuscitation (CPR) c. Give atropine per agency dysrhythmia protocol (WRONG) d. Provide supplemental O2 via non-rebreather mask
b. Start cardiopulmonary resuscitation (CPR
The nurse is preparing a health promotion pamphlet to distribute at a community center. It is appropriate for the nurse to include that certain heart valve problems can be avoided by doing which of the following? a. avoiding kissing and sharing eating utensils with people who have "mono" b. completing a prescription of antibiotics for treatment of "strep throat" c. drinking sports drinks to counteract the effects of a "stomach bug" d. receiving an annual vaccination to help prevent "the flu" (WRONG)
b. completing a prescription of antibiotics for treatment of "strep throat"
The nurse on the cardiac unit is assessing a client who was admitted with a diagnosis of acute pericarditis. Which of the following findings would be the priority to follow-up? a. visible distension in the veins of the client's neck b. scratching sound upon auscultation while the client is holding the breath c. client report of chest pain that is worse when the client is supine (WRONG) d. client report of chest pain that is worse with deep inspiration
b. scratching sound upon auscultation while the client is holding the breath
A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. b. bleeding time. c. prothrombin time. d. thrombin time.
bleeding time
The nurse is teaching a client who has chronic venous insufficiency about self-care. Which of the following information should the nurse include in the teaching? a. "Apply a topical antibiotic to any areas on your lower legs that have brown discoloration." b. "Routinely check the tips of your toes for ulcers that can occur in people with this condition." (WRONG) c. "Frequently flex and extend your ankles if you must remain standing for a long time at work." d. "Avoid eating green, leafy vegetables to minimize the risk for blood clots in your calves."
c. "Frequently flex and extend your ankles if you must remain standing for a long time at work."
The nurse is providing discharge teaching for a client who had laparoscopic cholecystectomy surgery 8 hours ago. Which of the following statements by the client would indicate a correct understanding of the teaching? a. "I will avoid eating concentrated sweets and simple carbohydrates." b. "I should drink fluids between meals rather than with meals." (WRONG) c. "I need to eat foods without a lot of fat." d. "I will drink at least 2 liters of fluid per day to prevent complications."
c. "I need to eat foods without a lot of fat."
The nurse is teaching a client who has just had a laparoscopic cholecystectomy. Which of the following instructions should the nurse include when providing discharge instructions to the client. (Select all that apply) a. Take baths rather than showers. b. Eat a low fiber diet and drink 8-10 glasses of water each day. c. Call the physician if you have a fever of greater than 101 degrees Fahrenheit. d. You will have 1-4 puncture sites in your abdomen. e. You can return to work and normal activities within one week of surgery.
c. Call the physician if you have a fever of greater than 101 degrees Fahrenheit. d. You will have 1-4 puncture sites in your abdomen. e. You can return to work and normal activities within one week of surgery.
A client recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which prescribed PRN medication will be the most appropriate for the nurse to give? a. Oral acetaminophen 1g b. IV morphine sulfate 4mg (WRONG) c. Oral ibuprofen 600mg d. Fentanyl 1mg IV
c. Oral ibuprofen 600mg
Which information given by a 70-yr-old client during a health history indicates to the nurse that the client should be screened for hepatitis C? a. The client frequently eats in fast-food restaurants. b. The client traveled to a country with poor sanitation. (WRONG) c. The client used IV drugs about 20 years ago. dterm-36. The client had a blood transfusion in 2005.
c. The client used IV drugs about 20 years ago
The nurse on a cardiac unit is admitting a client with a history of mitral regurgitation who presents with fever, arthralgias, and petechiae. It would be important for the nurse to ask if the client recently has done which of the following? a. taken a nonsteroidal anti-inflammatory medication (WRONG) b. driven in a car for a long distance c. had a dental procedure d. had a bone density test
c. had a dental procedure
The nurse at a cardiology practice is screening clients for cardiovascular conditions. The nurse should screen for which of the following? a. chronic venous insufficiency by asking clients if the skin on the legs is red when the legs are down b. chronic venous insufficiency by asking clients if the skin on the legs is shiny and taut (WRONG) c. peripheral artery disease by asking clients if they have leg pain when they walk d. peripheral artery disease by asking clients if they have leg swelling every day
c. peripheral artery disease by asking clients if they have leg pain when they walk
When evaluating the discharge teaching for a client with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the client says, "I will ________." a. walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week." (WRONG) b. buy some loose clothes that do not bind across my legs or waist." c. use a heating pad on my feet at night to increase the circulation." d. change my position every hour and avoid long periods of sitting with my legs crossed."
c. use a heating pad on my feet at night to increase the circulation."
The nurse on the cardiac unit understands the importance of annual influenza vaccination for clients with cardiac conditions. The nurse should encourage administration of the annual trivalent inactivated influenza vaccine for clients with which of the following conditions? Select all that apply. a. chronic constrictive pericarditis b. mitral valve regurgitation c. atrial fibrillation d. aortic stenosis e. chronic heart failure
chronic constrictive pericarditis mitral valve regurgitation atrial fibrillation aortic stenosis chronic heart failure
Which information obtained by the nurse in the endocrine clinic about a client who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider? a. client's blood pressure is 148/94 mm Hg. b. client has bilateral 2+ pitting ankle edema. c. client has not been taking the prescribed vitamin D. d. client abruptly stopped taking the medication 2 days ago.
client abruptly stopped taking the medication 2 days ago.
The nurse will plan discharge teaching about prophylactic antibiotics before dental procedures for which client? a. client being discharged after an exacerbation of heart failure b. client who had a mitral valve replacement with a mechanical valve c. client admitted with a large acute myocardial infarction d. client being treated for rheumatic fever after a streptococcal infection
client who had a mitral valve replacement with a mechanical valve
After receiving change-of-shift report, which client should the nurse assess first? a. client with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L b. client with stage 4 chronic kidney disease who has an elevated phosphate level c. client who has just returned from having hemodialysis and has a heart rate of 124/min d. client who is scheduled for the drain phase of a peritoneal dialysis exchange
client who has just returned from having hemodialysis and has a heart rate of 124/min
After receiving change-of-shift report, which client should the nurse assess first? a. client with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. client with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates c. client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d. client with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water
client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
Which admission order written by the health care provider for a client admitted with infective endocarditis (IE) and a fever would the nurse to implement first? a. Administer ceftriaxone 1g IV (WRONG) b. Arrange for transesophageal echocardiogram c. Give acetaminophen PRN for fever d. Obtain blood cultures drawn from 2 sites
d. Obtain blood cultures drawn from 2 sites
The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the client with infective endocarditis (IE) based on which assessment finding(s)? a. Increase in heart rate of 15 beats/minute with walking b. Fever, chills, and diaphoresis (WRONG) c. Petechiae on the inside of the mouth and conjunctiva d. Urine output less than 30 mL/hr
d. Urine output less than 30 mL/hr
During discharge teaching with an older client who had a mitral valve replacement with a mechanical valve, the nurse must instruct the client on which of the following concepts? a. need for frequent laboratory blood testing. b. correct method for taking the radial pulse. c. use of daily aspirin for anticoagulation. (WRONG) d. need to avoid any physical activity for 1 month.
d. need to avoid any physical activity for 1 month.
The nurse is assessing a client who has a suspected right hip fracture following a fall. Which of the following findings would require immediate follow up by the nurse? a. edema and ecchymosis over the right hip b. diminished pedal pulse and capillary refill greater than 3 seconds in affected extremity c. right leg appears shorter than the left leg and client reports pain level of 6 d. adduction of the affected extremity is noted
diminished pedal pulse and capillary refill greater than 3 seconds in affected extremity
The nurse is caring for a client diagnosed with prostatitis who is reporting burning and pain with urination. The nurse should document that the client is experiencing which of the following? a. dysuria b. polyuria c. nocturia d. hematuria
dysuria
The nurse is monitoring the serum laboratory results for a client who was admitted with acute pancreatitis 4 hours ago. Which of the following results may be seen with a client who has acute pancreatitis? Select all that apply. a. elevated bilirubin level b. decreased calcium level c. decreased serum glucose level d. decreased white blood cell (WBC) count e. elevated lipase and amylase
elevated bilirubin level decreased calcium level elevated lipase and amylase
When obtaining a health history and physical assessment for a 36-yr-old female client with possible multiple sclerosis (MS), the nurse should: a. inquire about urinary tract problems b. inspect the skin for rashes or discoloration c. assess for the presence of chest pain d. ask the client about any increase in libido
inquire about urinary tract problems
The nurse is assessing a client who reports having a sharp pain along the costovertebral angles. The nurse recognizes that this assessment finding might be due to which of the following? a. ovary infection b. spleen enlargement c. liver enlargement d. kidney inflammation
kidney inflammation
The nurse is caring for a client who is postoperative total thyroidectomy. The nurse notes that the client has hoarseness when speaking and reports tingling in the hands. Which of the following actions would be the most appropriate for the nurse to take? a. obtain a prescription to check the client's serum calcium level b. encourage the client to increase intake of oral fluids c. administer prescribed potassium chloride d. restrict the client's intake of sodium
obtain a prescription to check the client's serum calcium level
A client who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as: a. orthopnea. b. pulsus alternans. c. paroxysmal nocturnal dyspnea. d. acute bilateral pleural effusion.
paroxysmal nocturnal dyspnea
The nurse advises a client with myasthenia gravis (MG) to: a. anticipate the need for weekly plasmapheresis treatments b. perform physically demanding activities early in the day c. do frequent weight-bearing exercise to prevent muscle atrophy d. protect the extremities from injury due to poor sensory perception
perform physically demanding activities early in the day
The nurse is providing prenatal care to a woman who is pregnant and teaching measures to reduce her risk of postpartum cystocele, rectocele, and uterine prolapse. Which of the following interventions should the nurse recommend? a. preventing constipation b. maintaining good perineal hygiene c. Increasing fluid intake for 2 weeks postpartum d. performing pelvic floor muscle exercises
performing pelvic floor muscle exercises
The nurse is reviewing the laboratory results for a client who has Addison's disease. Which of the following results should the nurse expect? a. sodium 150 mEq/L b. glucose 250 mg/dL c. WBC 8,000L d. potassium 5.8 mEq/L
potassium 5.8 mEq/L
The nurse will plan to teach a 51-yr-old man who is scheduled for an annual physical examination about a(n) ______. a. prostate-specific antigen (PSA) testing b. increased risk for testicular cancer c. normal decreases in testosterone level d. possible changes in erectile function
prostate-specific antigen (PSA) testing
The nurse is caring for a client who is one hour postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions? a. supine with neck midline b. high-Fowler's with neck flexed c. semi-Fowler's with neck midline d. left lateral decubitus with neck flexed
semi-Fowler's with neck midline
The nurse on the cardiac unit is teaching a group of clients who have various cardiac dysrhythmias. Which of the following information would be appropriate for the nurse to teach? A client with ________. a. atrial fibrillation should avoid eating spinach and kale b. sinus bradycardia should avoid taking nasal decongestant medications c. sinus tachycardia should avoid drinking coffee d. first-degree atrioventricular block should avoid the use of oral antihistamines
sinus tachycardia should avoid drinking coffee
A 45-year-old female client reports to the nurse that when she sneezes, "I lose my urine." The nurse should document this finding as which of the following? a. urge incontinence b. stress incontinence c. urinary retention d. urinary frequency
stress incontinence
The nurse is assessing a client with Cushing's syndrome. Which of the following findings should the nurse expect to observe? (Select all that apply.) a. exophthalmos b. striations c. fatty, neck hump d. moon-face e. weight loss
striations fatty, neck humpmoon-face
The nurse is assessing a male client who reports sudden onset of severe scrotal pain and nausea. The nurse notes the absence of the cremasteric reflex. The nurse should suspect the client is experiencing which of the following conditions? a. hydrocele b. testicular torsion c. varicocele d. spermatocele
testicular torsion
While providing hygiene care for an older adult female client, the nurse observes tissue protruding from the client's vagina. Which of the following conditions should the nurse suspect the client is experiencing? a. cystocele b. rectocele c. herpes simplex virus, type 2 (HSV-2) d. uterine prolapse
uterine prolapse
