final study

A client with diabetic ketoacidosis has been brought into the ED. Which intervention is not a goal in the initial medical treatment of diabetic ketoacidosis? A. Administer glucose. B. Monitor serum electrolytes and blood glucose levels. C.Administer isotonic fluid at a high volume. D.Administer potassium replacements.

A. Administer glucose.

A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis? A. Albumin B. Calcium C. Sodium D. Potassium

A. Albumin

A patient with possible ischemic stroke has been aphasic for 2 hours and has a blood pressure of 220 /110. Which prescription by the healthcare provider should the nurse question? A. Labetalol infusion to keep the BP lower than 120/80 B. Tissue Plasminogen Activator per protocol C.IV normal saline at 75 ml/hr D. bed elevated to 30 degrees

A. Labetalol infusion to keep the BP lower than 120/80

A nurse is instructing a group of clients about nutrition. The nurse should include that which of the following foods is a good source of high- quality protein? A. Soybeans B. Grains C. Legumes D. Green vegetables

A. Soybeans

Which category of oral antidiabetic agents exerts the primary action by directly stimulating the pancreas to secrete insulin? A. Sulfonylureas B. Thiazolidinediones C. Biguanides D. Alpha-glucosidase inhibitors

A. Sulfonylureas

A client with type 1 diabetes reports waking up in the middle of the night feeling nervous and confused, with tremors, sweating, and a feeling of hunger. Morning fasting blood glucose readings have been 110 to 140 mg/dL. The client admits to exercising excessively and skipping meals over the past several weeks. Based on these symptoms, the nurse plans to instruct the client to: A. check blood glucose at 3:00 B. administer an increased dose of neutral protamine Hagedorn insulin in the evening. c. at a complex carbohydrate snack in the evening before bed. d. skip the evening neutral protamine Hagedorn insulin dose on days when exercising and skipping meals.

A. check blood glucose at 3:00

A nurse is teaching about medications to a group of clients. Which of the following statements by a client indicates a need for further teaching? A."I will take aspirin to reduce pain from my peptic ulcer. B."I will take ibuprofen for arthritis." C."I will take morphine during sickle cell crisis." D."I will take propranolol to manage high blood pressure."

A."I will take aspirin to reduce pain from my peptic ulcer.

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching? A."I'll be glad when I can stop taking this medicine." B."I will notify my doctor before taking any other medications." C. "I have made an appointment to see my dentist next week." D."I know that I cannot switch brands of this medication."

A."I'll be glad when I can stop taking this medicine."

A nurse is teaching a client who is preoperative for a colectomy. The client asks the nurse why he needs a large-bore NG tube. Which of the following statements should the nurse make? A."The tube will remove gas and fluid from your stomach." B."The tube is a routine standard following this type of surgery." C."The tube will allow us to provide you with nutrition." D."The tube can be explained to you once you are stable after surgery."

A."The tube will remove gas and fluid from your stomach."

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse notices that the solution bag is almost empty and there is not another bag of TPN to administer. Which of the following IV solutions should the nurse administer until the next bag of TPN solution is available? A.10% dextrose in water (D10W) B. sodium chloride (0.45% NaCl) C.Lactated Ringer's solution D.5% dextrose in lactated Ringer's solution (D5LR)

A.10% dextrose in water (D10W)

When the dawn phenomenon occurs, the patient has relatively normal blood glucose until approximate what time of day? A.3 AM b.5 AM c.7 AM

A.3 AM

A client has just been diagnosed with type 2 diabetes. The health care provider has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the healthcare provider prescribe for this client? A.A biguanide B.A sulfonylurea C.A thiazolidinedione D.An alpha-glucosidase inhibitor

A.A biguanide

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? A.A reddened area over the sacrum B.Stiffness in the lower extremities C.Difficulty moving the upper extremities D. Difficulty hearing some types of sounds

A.A reddened area over the sacrum

What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention? A.Albumin infusion B. Diuretic therapy C. Therapeutic paracentesis D. Platelet infusions

A.Albumin infusion

A nurse diabetes educator is planning an initial visit to a home care client who was recently diagnosed with diabetes mellitus. Which skills would the nurse help the client learn? A.All the above B.Planning an appropriate and consistent diet C.Self-administration of medication D.Self-monitoring of glucose levels

A.All the above

The nurse is caring for a client who has been prescribed glyburide. Which factor, if identified in the client history, would cause the nurse to inform the health care provider of a contraindication to use? A.Allergy to sulfonamides B.A diagnosis of hypertension C.The ingestion of carbohydrates D.Increase in alkaline phosphatase

A.Allergy to sulfonamides

A nurse is caring for a 48-year-old woman who has been hospitalized after injecting the wrong type of insulin. Which sign of hypoglycemia will the nurse be careful to observe? A.Blurred vision B.Dry skin C.Fruity breath D.None of the above

A.Blurred vision

A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? A.Carotid endarterectomy B.Stent placement C.Removal of the carotid artery D.Percutaneous transluminal coronary artery angioplasty

A.Carotid endarterectomy

A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take? A.Change the IV tubing every 24 hr. B.Obtain the client's blood glucose every 12 hr. C.Change the IV site dressing every 4 days. D.Weigh the client every other day.

A.Change the IV tubing every 24 hr.

A nurse on the day shift is preparing to change a client's total parenteral nutrition (TPN) solution, but the new TPN solution has not arrived from the pharmacy. The client receives additional IV fat emulsion during the night shift. Which of the following actions should the nurse take? A.Choice Hang dextrose 10% in water (D10W) until the TPN solution is delivered. B.Saline lock the IV catheter after discontinuing the TPN solution. C.Hang the IV fat emulsion solution. D. Call the provider for new TPN orders.

A.Choice Hang dextrose 10% in water (D10W) until the TPN solution is delivered.

A client has been taking aluminum hydroxide daily for the past 2 weeks. Which side effect would the nurse watch for? A.Constipation B. Hypernatremia C. Hyperkalemia D. Diarrhea

A.Constipation

The nurse is caring for a patient who sustained an ischemic CVA three hours ago. The patient's most recent blood pressure was 168/101. The nurse should take which action? A.Continue to monitor B.Place the patient in the supine position C.Obtain orthostatic blood pressure D.Request a prescription for an antihypertensive

A.Continue to monitor

The nurse is performing an initial assessment on a patient being admitted for acute pancreatitis. Which assessment data would support this diagnosis? A.Cullen Sign B.Homan Sign C. Rovsig Sign D.Kerning Sign

A.Cullen Sign

A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for? A.Decreased potassium level B.Elevated sodium level C.Elevated magnesium D.level Decreased calcium level

A.Decreased potassium level

Which of the following conditions would not be an indication of parenteral nutrition? A.Dumping Syndrome B.Chronic, Severe Diarrhea C.Small bowel obstruction D.None of the above

A.Dumping Syndrome

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? A.Establish the ability to communicate effectively. B.Compensate for loss of depth perception C.Learn to control impulsive behavior. D.Improve left-side motor function.

A.Establish the ability to communicate effectively.

The nurse is preparing to administer 20 units of NPH insulin to a client. Before administering the medication, the nurse should implement which intervention? A.Have a colleague confirm the dosage. B.Massage the chosen injection site. C.Assess the client's understanding of diabetes. D.Assess the client's urine for the presence of glucose.

A.Have a colleague confirm the dosage.

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority? A.Hematemesis B.Epigastric discomfort c.Dyspepsia D. Constipation

A.Hematemesis

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume? A.Increased urine osmolarity B.Cool, clammy skin Distractor C.Jugular vein distention D.Decreased serum sodium level

A.Increased urine osmolarity

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?A.Intellectual impairment B.Impaired sense of humor C.Loss of depth perception D.Poor judgment

A.Intellectual impairment

The nurse admits a client with type 2 diabetes who takes metformin (Glucophage).The nursing diagnosis given is an ineffective breathing pattern. What complication of the client's current drug therapy does the nurse believe the client is experiencing? A.Lactic acidosis B.Deficient fluid volume C.Fluid overload D.Hyperkalemia

A.Lactic acidosis

A client has refused a scheduled dose of metformin, stating that he/she is worried about inducing hypoglycemia because his/her blood glucose level is currently 66 mg/dL (3.66 mmol/L). The nurse should convey what teaching points to the client. A.Metformin does not cause hypoglycemia B..Hypoglycemia is only a risk in clients with type 1 diabetes. C.Overuse of metformin creates a risk for hyperglycemia, not hypoglycemia. D. If the client has been taking metformin for more than 3 to 4 weeks, there is no risk for hypoglycemia.

A.Metformin does not cause hypoglycemia

A client receives a daily injection of glargine insulin at 7:00 a.m. When should the nurse monitor this client for a hypoglycemic reaction? A.None of the above B.Between 8:00 and 10:00 a.m. C.Between 4:00 and 6:00 p.m. D.Between 7:00 and 9:00 p.m.

A.None of the above

The nurse observes the patient having a tonic-clonic seizure. Which appropriate action should the nurse take? A.Note the time when the seizure started B.Call a code blue. C.Step out of the room to quickly bring pads for the side rails. D.Raise the patient's Head of the bed.

A.Note the time when the seizure started

The 36 hr post appendectomy patient presents with abdominal guarding and complains of sudden, deep ,10/10 in severity of pain .The nurse should implement which action first ? A.Notify MD of the patient change in status B.Obtain an order for a PCA pump C.Administer PRN morphine D.Assess for other signs of pain

A.Notify MD of the patient change in status

The nurse is teaching a community class to people with type 2 diabetes mellitus. Which explanation explains the development of type 2 diabetes? A.Peripheral cells become resistant to circulating insulin. B.The patient eats too many foods high in sugar C.The islets cells in the pancreas stops producing insulin D.Insulin production is reduced caused by adrenal insufficiency.

A.Peripheral cells become resistant to circulating insulin.

Which stimulus is known to trigger an episode of autonomic dysreflexia in a client who has suffered a spinal cord injury? A.Placing a blanket over the client B. Diarrhea C.Placing the client in a sitting position D.Voiding

A.Placing a blanket over the client

A client newly diagnosed with type 1 diabetes asks the nurse why injection site rotation is important. What is the nurse's best response? A.Promote absorption. B.Avoid infection. C.Minimize discomfort. D.Prevent muscle destruction.

A.Promote absorption.

A nurse is preparing to discharge a client newly diagnosed with peptic ulcer disease. The client's diagnostic test results were positive for H. pylori bacteria. The health care provider has ordered the "triple therapy" regimen. Which medications will the nurse educate the client on? A.Proton-pump inhibitor and two antibiotics B.H2-receptor antagonist and two antibiotics C.H2-receptor antagonist, proton-pump inhibitor, and an antibiotic D.Proton-pump inhibitor, an antibiotic, and bismuth salts

A.Proton-pump inhibitor and two antibiotics

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider? A.Purplish-colored stoma B.Stoma oozing red drainage C.Shiny, moist stoma D.Rosebud-like stoma orifice

A.Purplish-colored stoma

The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? A.Reduce protein intake to 60 to 80 g/day B.Restrict Sodium Intake to 2g/day C. Limit Oral Fluids to 1500 ml D.Decrease the daily fat intake

A.Reduce protein intake to 60 to 80 g/day

A client with type 2 diabetes has been managing his blood glucose levels using diet and metformin. Following an ordered increase in the client's daily dose of metformin, the nurse should prioritize which of the following assessments? A.Reviewing the client's creatinine and BUN levels B.Monitoring the client's neutrophil levels C.Assessing the client for signs of impaired liver function C.Monitoring the client's level of consciousness and behavior

A.Reviewing the client's creatinine and BUN levels

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions? A.Shakiness and diaphoresis B.Excessive thirst and urination C.Fever and chills D.Hypertension and crackles

A.Shakiness and diaphoresis

A client with hypertension is diagnosed with type 2 diabetes. For which reason would the nurse closely monitor the client when giving glyburide with metoprolol? A.Signs of hypoglycemia may be masked. B.Blood pressure will increase. C.Blood glucose levels will increase. D.Orthostatic hypotension can develop.

A.Signs of hypoglycemia may be masked.

The nurse is administering misoprostol to a client with a diagnosis of peptic ulcer disease. The client asks the nurse about the medication. Which of the following explains the action of misoprostol? A.Stimulates secretion of mucus to protect the stomach mucosa B.Increases the speed of gastric emptying C.Works as an antacid D.Helps to break down food products by lowering acid production

A.Stimulates secretion of mucus to protect the stomach mucosa

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? A.Turn the client's head to the side. B.Check the client's motor strength. C.Loosen the clothing around the client's waist. D Document the time the seizure began.

A.Turn the client's head to the side.

A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education? A.When symptoms cease, the client will return to presymptomatic state. B. A TIA is an insidious, often chronic episode of neurologic impairment. C.Symptoms of a TIA may linger for up to a week. D.None of the above.

A.When symptoms cease, the client will return to presymptomatic state.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because they A.cannot tolerate a high glucose concentration. B. are at risk for gallbladder contraction. C.are at risk for hepatic encephalopathy. D.can digest high-fat foods

A.cannot tolerate a high glucose concentration.

A nurse is teaching a client who is postpartum and has been diagnosed with iron deficiency anemia. Which of the following dietary recommendations should the nurse include in the teaching plan? A. Yogurt and mozzarella B. Spinach and beef C. Milk and turkey slices D. Fish and cottage cheese

B. Spinach and beef

A client, being evaluated for diabetes, asks how a blood glucose test is used to diagnose this disease. What is the nurse's best response? A."A fasting blood sugar result of 126 mg/dL (6.99 mmol/L) or more on two separate occasions is diagnostic of diabetes." B."A fasting blood sugar result of 100 mg/dL (5.55 mmol/L) or more on two separate occasions is diagnostic of diabetes." C."A fasting blood sugar result of 100 mg/dL (5.55 mmol/L) or more and an A1C of more than 6 on two separate occasions are diagnostic of diabetes." D."Two consecutive glycosylated hemoglobin (hemoglobin A1C) results of 6 or more are diagnostic of diabetes."

B."A fasting blood sugar result of 100 mg/dL (5.55 mmol/L) or more on two separate occasions is diagnostic of diabetes."

A client newly diagnosed with type 2 diabetes has attended educational sessions to provide insight into the diagnosis. Which of the client's statements should prompt the nurse to provide further teaching? A.I'm disappointed, but I take some solace in the fact that I won't ever have to have insulin injections. B.I don't like getting this diagnosis, but I know that treatment now can prevent future health consequences. C.People always tried to encourage me to lose weight, and I suppose they might have been right. D.From what I've learned, I know that the basic problem is that my pancreas can't keep up with my insulin needs.

B.I don't like getting this diagnosis, but I know that treatment now can prevent future health consequences.

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Difficulty reading B.Inability to recognize his family members C.Right hemiparesis D.Aphasia

B.Inability to recognize his family members

A nurse is providing teaching about nutrition to a group of clients. The nurse should include that which of the following foods contains the highest level of thiamine per serving? A. 1 hard-boiled egg B. 1 cup dried pears C. 1 cup whole grain wheat flour D. 1 cup Brussel sprouts

C. 1 cup whole grain wheat flour

A nurse is caring for a client who requires total parenteral nutrition (TPN).Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly? A.Sit the client upright. B. Turn the client on his left side. C.Prepare to add insulin to the TPN infusion. D.Stop the TPN infusion.

D.Stop the TPN infusion.

The nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care? a. Admit the client to a private room b. Measure head circumference every shift c. Implement seizure precautions d. Place the client in a semi-Fowler's position

a. Admit the client to a private room

A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider? a. Amoxicillin-clavulanate b. Gentamycin c. Erythromycin d. Amphotericin B

a. Amoxicillin-clavulanate

A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching? a. Avoid eating within 3 hr of bedtime. b. Limit fluid intake not related to meals. c.Chew on mint leaves to relieve indigestion. d.Season foods with black pepper.

a. Avoid eating within 3 hr of bedtime.

A nurse is providing preoperative teaching to a client who is to undergo an open bowel resection at 1300 next week. Which of the following statements by the client indicates the need for further teaching? a. "I will be able to eat solid food when I wake up from anesthesia." b. "I will have a glass of juice the morning of my surgery." c."I understand what risks I can expect with this surgery." d. "I will take time to relax if I get nervous the night before surgery.

a. "I will be able to eat solid food when I wake up from anesthesia."

A nurse is providing teaching to a client who has peptic ulcer disease and a new prescription for sucralfate tablets. Which of the following information should the nurse provide? a. "Take sucralfate 1 hr before meals." b."An antacid may be taken with the medication if indigestion occurs." c."Take the tablets whole." d."Store sucralfate in the refrigerator."

a. "Take sucralfate 1 hr before meals."

A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider? a. 0.9% sodium chloride IV bolus b. Glucocorticoid medications c. Dextrose 5% in 0.45% sodium chloride d. Oral hypoglycemic medications

a. 0.9% sodium chloride IV bolus

A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link to crohns disease. Which of the following information should the nurse include? a. Both diseases are inflammatory b. Both diseases begin in the rectum c. The formation of fistulas is common with both diseases d. Both diseases require frequent surgeries

a. Both diseases are inflammatory

A nurse is teaching a client who has a new prescription for aluminum hydroxide to treat heartburn. The nurse should instruct the client to monitor for and report which of the following adverse reactions a. Constipation b. Flatulence c. Palpitations d. Headach

a. Constipation

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? a. Flush the NG feeding tube with 30 mL of water immediately following medication administration b. Mix the three medications together prior to administering. c. Dilute each medication with 10 mL of tap water. d.Maintain the head of the bed in a flat position for 30 min following medication administration.

a. Flush the NG feeding tube with 30 mL of water immediately following medication administration

A nurse is caring for a child who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer? a. Mannitol b. Hydroxyethyl glucose c. Dextran d. Albumin

a. Mannitol

A nurse is caring for a child who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take? a. Monitor urine output and weight b. Restrict fluid intake c. Administer oral corticosteroids d. Provide a low-carbohydrate diet

a. Monitor urine output and weight

A nurse is assessing a patient with suspected peritonitis. Which of the following findings should the nurse expect? a. Rigid abdomen b. Hyperactive bowel sounds c. Frequent bowel movements d. Increased urinary output

a. Rigid abdomen

A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation? a. Sudden abdominal pain b.Hyperactive bowel sounds c.Increased blood pressure d.Bradycardia

a. Sudden abdominal pain

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take before administering the tube feeding? a. Test the pH of gastric aspirate. b. Warm the feeding solution to body temperature. c.Place the client in low Fowler's position. d. Discard any residual gastric contents

a. Test the pH of gastric aspirate.

A nurse is admitting a child who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings? a. Widened pulse pressure b. Pupils reactive to light c. Elevated temperature d. Nuchal rigidity

a. Widened pulse pressure

carbohydrate intake needs when exercising. Which of the following foods should the nurse include as containing a 15 g serving of carbohydrates? a.1 cup milk b.2 slices bread c.1 cup sugar-free yogurt d.1 cup regular ice cream

a.1 cup milk

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care? a.Decrease the client's fluid intake. b.Increase the client's sodium intake. c. Decrease the client's carbohydrate intake

a.Decrease the client's fluid intake.

A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes mellitus? a.Fasting blood glucose 155 mg/dL b.HbA1c 5.5% c. 2 hr blood glucose 170 mg/dL d. Casual blood glucose 180 mg/dL

a.Fasting blood glucose 155 mg/dL

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? a.Prior to percussing the abdomen b.After palpating the abdomen c.After assessing for kidney tenderness d.Prior to inspecting the abdomen

a.Prior to percussing the abdomen

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? a.Review the client's electrolyte values b.Check the client's perianal skin integrity. c.Investigate the client's emotional concerns d.Obtain a dietary history from the client.

a.Review the client's electrolyte values

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? a.The nurse allows the client to rest in a supine position during feeding. b.The nurse initiates the feeding after aspirating 50 mL of gastric residual. c.The nurse irrigates the NG tube with tap water after feeding. d.The nurse administers the feeding through a syringe barrel by gravity.

a.The nurse allows the client to rest in a supine position during feeding.

A nurse is providing teaching about ileostomy care to a patient. Which of the following statements by the patient indicates a need for further teaching? a. "I will empty my pouch when it becomes 1/3 full" b. "I will be certain to take enteric-coated medications." c. "I will change my entire pouch system at least weekly." d. "I will use caution when eating high-fiber foods."

b. "I will be certain to take enteric-coated medications."

A nurse is assessing a child who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? a. Kernig's sign b. Brudzinski's sign c. Bradykinesia d. Nuchal rigidity

b. Brudzinski's sign

A nurse is teaching a patient who has a history of ulcerative colitis and a new diagnosis of anemia.Which of the following manifestations of ulcerative colitis should the nurse identify as a contributing factor to the development of the anemia a. Dietary iron restrictions b. Chronic blood loss c. intestinal malabsorption d. intestinal parasites

b. Chronic blood loss

A nurse is providing dietary teaching for a child who has Cushing's disease. Which of the following recommendations should nurse include in the teaching? a. Limit intake of postassium-rich foods b. Restrict sodium intake c. Decrease protein intake d. Increase carbohydrate intake

b. Restrict sodium intake

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? a. Obtain a diet history b. Assess the patients perianal skin integrity c. Check the patients electrolyte values d. Assess the patients emotional concerns

c. Check the patients electrolyte values

A nurse is assessing a child who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect? a. Tremors b. Hirsutism c. Hyperpigmentation d. Purple striations

c. Hyperpigmentation

A nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take? a. Discuss the manifestations of hyperglycemia with the parents b. Place the child on a low-sodium diet c. Teach the parents about cortisol replacement therapy d. Monitor the child for fluid volume excess

c. Teach the parents about cortisol replacement therapy

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

c. Time and observe and record the details of the seizure and postictal state.

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? a. To confirm the placement of the NG tube b.To remove gastric acid that might cause dyspepsia c.To identify delayed gastric emptying d. To determine the client's electrolyte balance

c.To identify delayed gastric emptying

A nurse is caring for a patient who received an injection of penicillin. The patient begins to experience dyspnea and tongue swelling. Which of the following actions should the nurse perform first? a. Administer IV fluids b. Document the observend data in the EHR c. Administer a dose of aminophylline by inhalation d. Administer epinephrine intramuscularly

d. Administer epinephrine intramuscularly

A nurse is reviewing the provider's prescriptions for a client experiencing a paralytic ileus following an appendectomy. Which of the following actions should the nurse expect to take? a. Administer an antacid medication b. Administer a bulk-forming agent such as Metamucil c. Apply an abdominal binder d. Insert a Nasogastric tube

d. Insert a Nasogastric tube

A nurse is assessing a patient who returned to the unit 4 hours ago after a partial colectomy. Which of the following findings should the nurse prioritize first? a. SaO2 of 95% b. Distended bladder c. Moderately saturated dressing d. Severe incisional pain

d. Severe incisional pain

A nurse is caring for a child who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? a. Seizures b. Burns c. Dehydration d. Shivering

d. Shivering

A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan? a. Soak in a sitz bath for 20 minutes after each stool b. Administer a soap-suds enema to cleanse the colon c. Cleanse with anti-microbial scrub and dry vigorously d. Wipe perianal area with warm water and apply a barrier cream

d. Wipe perianal area with warm water and apply a barrier cream