HESI 2
which nursing intervention would the nurse avoid when providing care for a client with a fractured extremity? 1. keep the client warm and dry 2. remove the client's shoes or boots immediately 3. immobilize the affected extremity 4. allow the client to lie in supine position
2
which topic would be the most important to include in teaching when an obese client receives a diagnosis of high blood pressure? 1. causes of hypertension 2. symptoms of hypertension 3. effect of weigh loss in hypertension 4. effect of lowering alcohol intake in hypertension
3
which topic would the nurse include when teaching a client who is being treated fro active tuberculosis and has a productive cough? 1. reasons to avoid going outside 2. need for continued hospitalization 3. use of disposable tissues when coughing 4. benefits of attending community events
3
which characteristic of urine changes in the presence of a urinary tract infection (UTI)? 1. clarity 2. viscosity 3. glucose level 4. specific gravity
1
which clinical manifestation is associated with cellulitis? 1. lymphadenopathy 2. occasional papules 3. vesicles that evoke into pustules 4. isolated erythematous pustules
1
which key feature is associated with a stage 2 pressure ulcer? 1. presence of non intact skin 2. development of sinus tracts 3. damage to the subcutaneous tissues 4. appearance of a reddened area over a bony prominence
1
which statement by a client receiving diuretic therapy indicates that the teaching about potassium supplements is understood? 1. "I will report any abdominal distress" 2. "I should use salt substitutes with my food" 3. "the medication must be taken on an empty stomach" 4. "the dosage is correct if my urine output increases"
1
a client is admitted with the diagnosis of acute pancreatitis. which clinical manifestation would the nurse assess in the client? (select all that apply) 1. jaundice 2. acute pain 3. hypertension 4. hypoglycemia 5. increased amylase
1, 2, 5
which parental statement indicates effective learning regarding management of nocturnal enuresis in a 6 yo child? (select all that apply) 1. "I should avoid giving my child fluids after dinner" 2. "I should encourage my child to drink lots of water during the day" 3. "I should make my child wear diapers during say hours while at school" 4. "I should give my child diet soda instead of regular soda in the evening" 5. "I should wake my child at the sea time every night to use the bathroom"
1, 2, 5
which would the nurse teach parents about preventing sudden infant death syndrome (SIDS)? (select all that apply) 1. restrain from smoking around the infant 2. avoid co-sleeping or bed-sharing 3. position the infant on the side while sleeping 4. use soft pillows to support the infant while sleeping 5. refrain from placing stuffed toys on the infant's bed
1, 2, 5
the nurse is taking are of a client with cirrhosis of the liver. which clinical manifestations would the nurse assess in the client? (select all that apply) 1. ascites 2. hunger 3. pruritis 4. jaundice 5. headache
1, 3, 4
an infant with persistent diarrhea is subject to significant fluid and electrolyte alterations. which physiologic imbalance would the nurse most likely encounter? (select all that apply) 1. hypovolemia 2. hyperkalemia 3. hypercalcemia 4. metabolic acidosis 5. decreased hematocrit
1, 4
when teaching a client with hypertension about a 2-gram sodium diet, which foods would the nurse instruct the client to avoid? (select all that apply) 1. canned chili 2. ground beef 3. fresh salmon 4. luncheon meat 5. cooked broccoli
1, 4
which findings are consistent with hypercalcemia after prolonged immobility? (select all that apply) 1. bone pain 2. convulsions 3. muscle spasms 4. tingling of extremities 5. depressed deep tendon reflexes
1, 5
when palpating the chest during a respiratory assessment, which finding would the nurse expect in a client with pneumonia? 1. bilateral decreased chest expansion 2. increased remits over the affected area 3. tracheal deviation away from the affected side 4. decreased chest expansion on the affected side
2
when teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis (DVT)? 1. pregnancy 2. inactivity 3. aerobic exercise 4. tight clothing
2
which clinical finding would the nurse expect when assessing an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS)? 1. visible peristaltic waves across the lower abdomen 2. palpable mass in the epigastric area to the right of the umbilicus 3. tenderness over the epigastric region not relieved by heat application 4. lower abdominal distention with vomiting of bile-stained gastric contents
2
which condition would the nurse suspect in a client reporting fever, redness, skin breakdown, and inflammation on the leg with an area that is tender and edematous with diffused borders? 1. shingles 2. cellulitis 3. folliculitis 4. onychomycosis
2
which finding would the nurse expect int eh urinalysis report of a client with diabetes insipidus? 1. pH of urine: 9 2. specific gravity of urine: 0.4 3. red blood cells (RBCs) in urine: 6 hpf 4. white blood cells (EBCs) in urine: 8 hpf
2
which information would the nurse include when teaching parents about the basic problem in celiac disease? 1. green stools 2. intolerance of gluten 3. absence of intestinal villi 4. susceptibility to severe dehydration
2
which phrase describes a greenstick fracture? 1. more than two fragments 2. incomplete with one side bent 3. spontaneous, at the site of bone disease 4. across the longitudinal axis of the bone shaft
2
which response would a nurse give when a client asks what to expect when beginning treatment for tuberculosis? 1. "therapy will last a few weeks" 2. "therapy will occur over two phases" 3. "therapy will involve on medication" 4. "therapy will require monitoring kidney function"
2
why is the vomitus of an infant with pyloric stenosis white rather then bile-stained? 1. the pyloric sphincter obstructs the bile duct 2. there is an obstruction above the opening of the common bile duct 3. the bile duct sphincter is connected to the hypertrophied pyloric muscle 4. there is construction of the cardiac sphincter that obstructs the flow of bile
2
a client with acute kidney injury is moved into the diuretic phase after 1 week of therapy. during this phase, which clinical indicators would the nurse assess? (select all that apply) 1. skin rash 2. dehydration 3. hypovolemia 4. hyperkalemia 5. metabolic acidosis
2, 3
which signs of hypokalemia would the nurse monitor in the postoperative surgical client with a nasogastric tube attached to continuous low suction? 1. irritability 2. dysrhythmias 3. muscle weakness 4. abdominal cramps 5. acidosis
2, 3
while obtaining a client's health history, which factor would the nurse identify as predisposing the client to type 2 diabetes? 1. having diabetes insipidus 2. eating low-cholesterol foods 3. being 20 pounds overweight 4. drinking a daily alcoholic beverage
3
which clinical manifestation will the nurse assess for in a client with a serum potassium level of 6.4 mEq?L? (select all that apply) 1. anorexia 2. constipation 3. muscle weakness 4. irregular hart rhythm 5. hyperactive bowel tones
3, 4, 5
which finding in the older adult client is associated with a urinary tract infection (UTI)? (select all that apply) 1. dysuria 2. urgency 3. confusion 4. incontinence 5. slight rise in temperature
3, 4, 5
the nurse is eliciting a health history from a client with ulcerative colitis. which factor would the nurse consider to be most likely associated with the client's colitis? 1. food allergy 2. infectious agent 3. dietary components 4. genetic predisposition
4
which factor would the nurse consider when the parent of a 10 month old infant expresses frustration that this is the baby's third otitis media in 3 months? 1. analgesics are contraindicated 2. oral antibiotics will be prescribed 3. the labyrinth and cochlea are inflamed 4. the Eustachian tube is short and horizontal
4
which finding would the nurse expect when assessing a client who has a funeral calculus? 1. could odor and dark urine 2. urgency and mild aching pain 3. frequency with small amounts of urine 4. hematuria with sharp pain when voiding
4
an infant with a diagnosis of heart failure is being given furosemide twice a day. which laboratory value would the nurse expect to the health care provider? 1. sodium of 140 2. ionized calcium of 2.35 3. chloride of 102 4. potassium of 3.0
4
the nurse is providing instruction to a parent of a child with influenza. which statement by the parents indicates the need for further instruction? 1. "i'll manage the fever with baby aspirin" 2. "we'll make sure to get a flat shot next season" 3. "providing fluids will help relieve the symptoms" 4. "staying home from school will prevent transmission"
1
the nurse is providing nutrition instructions for a client who has inflammatory bowel disease of the ascending colon. which suggestion by the nurse is appropriate? 1. consume scrambled eggs and applesauce 2. consume barbecued chicken and French fries 3. consume fresh fruit salad with cheddar cheese 4. consume chunky peanut butter on while wheat bread
1
which action would be appropriate to implement when collecting a 24 hour urine test? 1. start the time of the test after discarding the first voiding 2. discard the last voiding in the 24 hour period for the test 3. insert a urinary retention catheter to promote the collection of urine 4. strain the urine after each voiding before adding the urine to the container
1
which blood gas result would the nurse expect an adolescent with diabetic ketoacidosis to exhibit? 1. pH 7.30, CO2 40, HCO3 20 2. pH 7.35, CO2 47, HCO3 24 3. pH 7.46, CO2 30, HCO3 24 4. pH 7.50, CO2 50, HCO3 22
1
which medication may contribute to development of a peptic ulcer in a client receiving immunosuppressive therapy? 1. prednisone 2. azathioprine 3. cyclosporine 4. cyclophosphamide
1
which clinical findings would the nurse expect to identify when completing a nursing admission history and physical on a client with suspected hyperthyroidism? (select all that apply) 1. palpitations 2. tachycardia 3. thickened skin 4. apathetic attitude 5. missed menstrual periods
1, 2, 5
which nursing action would the nurse take when a child with a seizure disorder has a generalized seizure? (select all that apply) 1. assessing the seizure 2. taking the child's vital signs 3. turning the child on the side 4. pulling the padded side rails up 5. initiating oxygen (O2) administration
1, 3, 4
the nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. which instruction would the nurse include in the teaching plan? (select all that apply) 1. the client should obtain a finger=stick blood glucose reading before each meal 2. the client does not need to follow a specific diet until insulin is required 3. the teaching plan should include signs and symptoms of hypoglycemia 4. the teaching plan should include how to administer regular insulin 5. the teaching plan should include sick day rules
1, 3, 5
the nurse is completing an assessment on an older adult who fell and fractured the left hip. which clinical indicator would the nurse identify as typical with a fractured left hip? 1. left hip is ecchymotic 2. left leg is noticeably shorter than the right 3. left leg is internally rotated 4. left hip is tender when touched
2
when the nurse is reviewing a scent's arterial blood gas results, which finding would the nurse identify as being consistent with respiratory alkalosis? 1. a decreased pH, elevated PCO2 2. an elevated pH, decreased PCO2 3. a decreased pH, decreased PCo2 4. an elevated pH, elevated partial pressures of carbon dioxide (PCO2)
2
which action would the nurse include in the plan of care for a 6 month old infant with respiratory syncytial virus (RSV) who is in respiratory distress? 1. begin a clear fluid diet 2. maintain droplet and contact precautions 3. administer prescribed antibiotic immediately 4. allow parents and siblings to room in with the infant
2
which action would the occupational health nurse take after a tuberculin skin test (TST) on a nurse working int eh emergency department revealed an 11 mm induration? 1. plan for a repeat TST in 1 year 2. schedule the nurse for a chest x-ray 3. ask the nurse to provide sputum specimens 4. teach about the multiple drug treatment regimen
2
which client is most at risk for osteoporosis? 1. a nonsmoking 60 yo woman, body mass index (BMI) 27. 1 2. a 66 yo white woman, body mass index (BMI) 18, who is a paralegal 3. a 68 yo black woman, body mass index (BMI) 23.3, who is a retired receptionist 4. a 62 woman, body mass index (BMI) 23.2, who takes calcium carbonate daily
2
which condition would the nurse suspect in a 6 yo child who was admitted with abdominal pain and guarding, nausea, anorexia, and pain with palpation of the right lower quadrant? 1. viral infection 2. inflamed appendix 3. irritable bowel 4. parasitic infestation
2
which priority nursing intervention would the nurse implement when caring for a client with pneumonia? 1. increase fluid intake 2. instruct client on breathing exercises and controlled coughing 3. encourage client to ambulate as much as possible 4. maintain a nothing-by-mouth (NPO) status
2
which topic would the nurse include when doing discharge teaching about ways to avoid another venous thrombosis when caring for a client hospitalized with deep veins thrombosis? 1. daily aspirin use 2. frequent ambulation 3. warm soaks to legs 4. avoidance of cold
2
which medications would the nurse anticipate teaching the parent about for a preschooler newly diagnosed with cystic fibrosis? (select all that apply) 1. steroids 2. antibiotics 3. antihistamines 4. pancreatic enzymes 5. fat-soluble vitamins
2, 4, 5
the nurse provides education for a client about prophylactic measures that minimize the risk of contracting hepatitis B. which actions would be included in the teaching plan? (select all that apply) 1. preventing constipation 2. screening of blood donors 3. avoiding shellfish in the diet 4. limiting hepatotoxic medication therapy 5. maintaining a monogamous sexual relationship
2, 5
when the health care provider prescribes a diet high in potassium for a client who is taking a daily diuretic, which foods will the nurse suggest that the client eat? (select all that apply) 1. corn 2. banans 3. strawberries 4. cucumber salad 5. baked potatoes with skins
2, 5
which factor is a likely cause of hyponatremia? (select all that apply) 1. diabetes insipidus 2. profuse diaphoresis 3. excess sodium intake 4. removal of the parathyroid glands 5. rapid intravenous (IV) infusion of 5% dextrose in water (D5W)
2, 5
a client sustained minor skin injuries after an accident. which event occurs close to the time of injury? 1. thinning of the scare tissue 2. formation of granulation tissue 3. migration of leukocytes to the site of injury 4. arrival of fibroblasts to the site of infection
3
a parent whose infant is born with talipes equinovarus (clubfoot) tells the nurse, "I am afraid to have more children because they might have the same problem." which response by the nurse is the best? 1. reassuring the parent that this problem is unlikely to occur again 2. discussing the probability of the defect occurring in future children 3. exploring the parent's understanding of the probable causes of this disorder 4. explaining that there is no way of knowing whether the deformity will occur in a future child
3
the nurse is caring for a client after abdominal surgery and encourages the client to engage in deep-breathing exercises and turn from side to side. which complication is the nurse trying to prevent? 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis
3
the nurse understands which anti epileptic medication would be used as the first-line treatment for absence seizures? 1. phenytoin 2. diazepam 3. valproic acid 4. acetazolamide
3
when a client who is taking a diuretic has been instructed to eat foods high in potassium, which fruit would the nurse suggest? 1. apples 2. grapes 3. cantaloupe 4. cranberries
3
which adverse medication effect will a nurse monitor for in a client with cirrhosis of shelver who develops ascites and is prescribed spironolactone? 1. bruising 2. tachycardia 3. hyperkalemia 4. hypoglycemia
3
which autoimmune disease affects the central nervous system? 1. uveitis 2. celiac disease 3. multiple sclerosis 4. goodpasture syndrome
3
which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities? 1. thermography 2. plethysmography 3. duplex venous doppler 4. somatosensory evoked potential
3
which effect of lorazepam is the reason it is given to a client with status epileptics? 1. decreases anxiety associated with seizures 2. promotes rest after the seizure episode 3. depresses the central nervous system (CNS) 4. provides amnesia for the convulsive episode
3
which event occurs in the proliferative phase of wound healing? 1. thinning of scar tissue 2. strengthening of collagen 3. formation of granulation tissue 4. increase in capillary permeability
3
which medication will the nurse question when it is prescribed for a client with acute pancreatitis? 1. ranitidine 2. cimetidine 3. meperidine 4. promethazine
3
which term would the nurse use to describe the exudate characteristic of a serosanguineous wound? 1. greenish-blue pus 2. creamy yellow exudate 3. blood-tinged amber fluid 4. beige pus with a fishy odor
3
which test result would confirm the diagnosis of benign prostatic hyperplasia (BPH)? 1. digital rectal examination 2. serum phosphatase level 3. biopsy of prostatic tissue 4. massage of prostatic fluid
3
which type of acid-base imbalance would the nurse expect in a Chile admitted with a severe asthma exacerbation? 1. metabolic alkalosis caused by excessive production of acid metabolites 2. respiratory alkalosis caused by accelerated respirations and loss of carbon dioxide 3. respiratory acidosis caused by impaired respirations and increased formation of carbonic acid 4. metabolic acidosis caused by the kidney's inability to compensate for increased carbonic acid formation
3
the nurse is caring for ac Lent with suspected appendicitis. which assessment finding would the nurse determine would further support the diagnosis? 1. fever and malaise 2. nausea and vomiting 3. absolute constipation 4. pain in right lower quadrant
4
the nurse is teaching a client about gastroesophageal reflux disease (GERD). which statement made by the client indicates correct understanding of GERD management? 1. "three meals per day is the best regimen to avoid GERD symptoms" 2. "I can reduce my GERD symptoms through a high-carbohydrate, low-fat diet" 3. "a snack at bedtime will help reduce the acidity of my stomach during the night" 4. "I will place a 6 inch (15 cm) block under the head of the y bed to help with digestion"
4
the nurse is teaching pursed-lip breathing to a client with chronic obstructive pulmonary disease (COPD). the client asks about the benefit of the exercises. which explanation would the nurse give? 1. prevents complications that are associated with COPD 2. relieves shortness of breath by increasing the breath rat e 3. increases the amount of air that the client can inhale with each breath 4. keeps the airway open longer to decrease the work that goes into breathing
4
the registered nurse is caring for a client with peptic ulcers and dysphagia. which task would not be delegated to an unlicensed assistive personnel (UAP) who is assisting in the care of a client with peptic ulcers and dysphagia? 1. assisting the client with feeding 2. assisting the client with bathing 3. assisting the client in oral hygiene 4. assisting the client in administering the medications
4
when teaching a group of older adults about difference between the common cold and influenza, the nurse would educate the clients that it is most important to communicate with the health care provider about which symptom? 1. earache 2. sneezing 3. nasal stiffness 4. elevated temperature
4
which action is the priority when the preoperative nurse learns that a client is taking several herbal supplements? 1. provide the client with information about the usefulness of herbal therapies 2. inform the client about taking supplemental vitamins rather than herbs 3. teach the client about herbal supplements 4. ask the client which herbs have been taken
4
which assessment finding for a client with pneumonia would be most important for the nurse to communicate to the health care provider? 1. cough productive of rust-colored sputum 2. sharp chest pain with deep inspiration 3. oral temperature 103 F 4. respiratory rate 38 breaths per minute
4
which clinical manifestation would the nurse associate with benign prostatic hyperplasia? 1. perineal edema 2. urethral discharge 3. flank pain radiating to the groin 4. distention of the lower abdomen
4
which education would the nurse provide the parent of a boy born with hypospadias about the age in which the repair of this congenital defect is typically performed? 1. shortly after birth 2. between 4 and 5 years of age 3. just before the onset of puberty 4. after 6 months and before 1 year of age
4
which is the priority of care for a child who was recently diagnosed with celiac disease? 1. preventing celiac crisis and resulting problems 2. minimizing complications of respiratory involvement 3. teaching the parents to establish a diet that promotes optimal growth 4. helping the parents and child adjust to the long-term dietary restrictions
4
which clinical manifestation exhibited by a client taking levothyroxine for hypothyroidism for 3 month should cause a nurse to suspect that a decrease in dosage is needed? (select all that apply) 1. tremors 2. bradycardia 3. somnolence 4. heat intolerance 5. decreased blood pressure
1, 4
which factors contribute to development of osteoporosis in female clients? (select all that apply) 1. cigarette smoking 2. moderate exercise 3. use of street drugs 4. familial predisposition 5. inadequate intake of dietary calcium
1, 4, 5
which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful? 1. apples 2. kidney beans 3. cherries 4. brussel sprouts
2
which client seen at a health fair will be most at risk for hypertension? 1. 23 yo white man 2. 44 yo white woman 3. 50 yo Mexican-american woman 4. 62 yo African american man
4
which risk would the nurse monitor when providing care for a client with scoliosis of the thoracic spine and lumbar spine? 1. osteoarthritis 2. muscle spasticity 3. intervertebral disc prolapse 4. cardiac function impairment
4
which action would the nurse take after obtaining client blood pressures of 172/104 and 164/98 during a blood pressure screening? 1. provide health teaching about a low-sodium diet 2. call the paramedics for transport to the hospital 3. suggest ways to decrease the client's stress level 4. refer the client to a primary health care provider
f4
which type of fracture is common in preschool children? 1. greenstick 2. transverse 3. compound 4. comminuted
1
which statement indicates effective discharge teaching for a client with osteomyelitis? (select all that apply) 1. "I will take the antibiotic at the same time every day" 2. "I will take the antibiotic regularly until my symptoms subside" 3. "I will take the antibiotic with food if I develop gastric distress when on the antibiotic" 4. "I will notify my health care provider and stop taking the medication if I develop a rash or shortness of breath" 5. "I will need to change my diet to avoid milk products while on these antibiotics"
1, 3, 4
which clinical finding would the nurse expect to identify when caring for a client with a left leg venous thrombosis? (select all that apply) 1. pain in the left calf 2. intermittent claudication 3. redness in the affected area 4. swelling of the lower left leg 5. ecchymotic areas at the left ankle 6. localized warmth in the lower left leg
1, 3, 4, 6
which finding would the nurse expect when assessing a client with peripheral arterial disease? (select all that apply) 1. parllor of feet 2. warm extremities 3. ulcers on the toes 4. thick, hardened skin 5. delayed capillary refill
1, 3, 5
a 5 yo Chad complains of abdominal pain with nausea, anorexia, and a low-grade fever. palpation of the right lower quadrant of the abdomen elicits pain. which condition would the nurse suspect? 1. ulcerative colitis 2. acute appendicitis 3. hirschsprung disease 4. hookworm manifestation
2
a child with type 1 diabetes is receiving 15 units of regular insulin and 20 units of NPH insulin at 7:00 AM each day. which time would the nurse anticipate a hypoglycemic reaction from the NPH insulin to occur? 1. before noon 2. in the afternoon 3. within 30 minutes 4. during the evening
2
a client who is slightly overweight is preparing for discharge from the hospital after a cholecystectomy. which is important for the nurse to include in teaching the client about nutrition? 1. listing low-protein foods that may be included in the diet 2. explaining that fatty foods may not be tolerated for several weeks 3. teaching the importance of a low-calorie diet to promote weight reduction 4. encouraging the intake of high vitamin C, vitamin A, and zinc foods at each meal
2
a primary health care provider diagnoses the client's condition as otitis media. which assessment finding supports that diagnosis? 1. nodules on the pinna 2. redness of the eardrum 3. lesions in the external canal 4. excessive cerumen in the external canal
2
the nurse educator of a college health course is discussing tattoos with the class. which type of hepatitis associated with tattoos would the nurse include in the teaching plan? 1. hepatitis A 2. hepatitis C 3. hepatitis D 4. hepatitis E
2
the nurse is caring for a client who is positive for hepatitis A. which precautions would the nurse take? 1. wear a gown when entering the client's room 2. use gloves when removing the client's bedpan 3. clean eating utensils with bleach after use 4. wear a high-efficiency particulate air (HEPA) respirator when entering the client's room
2
the nurse is caring for a client with acute pancreatitis. which elevated laboratory test result is most indicative of acute pancreatitis? 1. blood glucose 2. serum lipase 3. serum bilirubin level 4. white blood cell count
2
which preoperative actions would the nurse plan when caring for a Clint scheduled for a septoplasty? (select all that apply) 1. teach the client how to use hot compresses 2. encourage the client to quit smoking before surgery 3. observe the surgical site for edema 4. teach the client about postsurgery activities that are restricted 5. assess the client's respiratory status 6. encourage the client to take aspirin before the surgery
2, 3, 4, 5
which manifestation would the nurse expect to find when assessing a client with hyperthyroidism? (select all that apply) 1. dry skin 2. weight loss 3. tachycardia 4. restlessness 5. constipation 6. exophthalmos
2, 3, 4, 6
a client is hospitalized with a diagnosis of acute pancreatitis. the plan of care is focused not eh goals of maintaining nutrition, promoting rest, maintaining fluids and electrolytes, and decreasing anxiety. which interventions would the nurse implement? (select all that apply) 1. provide a low-fat diet 2. administer analgesics 3. teach relaxation exercises 4. encourage walking in the hall 5. monitor cardiac rate and rhythm 6. observe for signs of hypercalcemia
2, 3, 5
which medication would the nurse anticipate being beneficial for a client on antipsychotic medication therapy who develops parkinsonism? (select all that apply) 1. levodopa 2. benztropine 3. amantadine 4. bromocriptine 5. dephenhydramine
2, 3, 5
which topic would the nurse include in teaching for a client with a new diagnosis of hypertension? (select all that apply) 1. reason for daily low-dose aspirin use 2. use of a home blood pressure monitor 3. adverse effects of tobacco on blood pressure 4. avoidance of any alcohol consumption 5. benefits of moderate daily exercise
2, 3, 5
which finding would indicate a need to refer a client to a health care provider when the nurse is screening clients for hypertension? 1. report of pain as the blood pressure cuff is inflated 2. systolic blood pressure result higher than 120 3. diastolic blood pressure reading greater than 89 4. loud Korotkoff sounds as the blood pressure cuff is deflated
3
which information about a clients condition would the nurse consider when providing care to a client who just received radioactive iodine for Graves disease? 1. not radiate and can be handled as nay other individual 2. highly radioactive and should be isolated as much as possible 3. mildly radioactive and should be treated with routine safety precautions 4. not radioactive by may still transmit some dangerous radiations and must be treated with precautions
3
which information about being prostatic hyperplasia (BPH) is important for the nurse to consider when caring for a client with that condition? 1. it is a congenital abnormality 2. a malignancy usually results 3. it predisposes to hydronephrosis 4. prostate-specific antigen decreases
3
a client develops an intestinal obstruction. a nasogastric tube is inserted and connected to low, continuous suction. the nurse monitors the client for fluid volume deficit. which clinical finding would the nurse expect if the client becomes dehydrated? 1. restlessness 2. constipation 3. inelastic skin turgor 4. increased blood pressure
3
a client is admitted with an acute onset of high tower quadrant pain at McBurney point, and appendicitis in suspected. for which clinical indicator would the nurse assess the client to determine if the pain is secondary to appendicitis? 1. urinary retention 2. gastric hyperacidity 3. rebound tenderness 4. increased lower bowel motility
3
a client is being treated for influenza A )H1N1). the nurse has provided instructions to the client about how to decrease the risk of transmission to others. which statement by the client indicates a need for further instruction? 1. "I should practice respiratory hygiene/cough etiquette" 2. "I should avoid contact with older adults or children" 3. "I should obtain a pneumococcal vaccination each year" 4. "I would allow visitors for short periods of time only"
3
the nurse is caring for a child with severe dehydration and its associated acid-base imbalance. which compensatory mechanism within the body. is activated to counteract the effects of the child's acid-base imbalance? 1. profuse diaphoresis 2. increased temperature 3. increased respiratory rate 4. real retention of hydrogen ions
3
how would the nurse arrange the order of steps in normal wound healing in the proliferative phase? 1. migration of mitotic fibroblast cells into the wound 2. buildup of inflexible scar tissue 3. formation of scaffold or frameworks 4. contraction of capillary buds and a collagen deposit form that granulation tissue 5. formation of capillaries in areas surrounding the wound 6. growth of epithelial cells over the granulation tissue bed
3, 1, 2, 5, 4, 6
a client is diagnosed with celiac disease. which foods would the nurse teach the client to avoid? (select all that apply) 1. corn 2. cheese 3. oatmeal 4. rye bread 5. fruit juice
3, 4
which assessment findings would indicate a possible asthma exacerbation? (select all that apply) 1. fever 2. stridor 3. wheezing 4. tachycardia 5. hypotension
3, 4
which condition would the nurse suspect in a client who complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination with a digital rectal examination report indicating smooth, firm, and enlarged prostate tissue surrounding the urethra? 1. prostatitis 2. paraphimosis 3. prostate cancer 4. benign prostatic hyperplasia (BPH)
4
which definition would the nurse use to explain osteoporosis? 1. it is avascular necrosis 2. it is caused by pathological fractures 3. it is hyperplasia of osteoblasts 4. it involves a decrease in bone substance
4
a 15 yo adolescent is found to have type 1 diabetes. which would the nurse include when teaching the adolescent about type 1 diabetes? 1. it does not always require insulin 2. it involves early vascular changes 3. it occurs more often in obese adolescents 4. it has a more rapid onset than does type 2 diabetes
4
a client asks the nurse what causes Parkinson disease. which description of pathology would the nurse provide in response to the client? 1. disintegration of the myelin sheath 2. breakdown of upper and lower neurons 3. reduced acetylcholine receptors at synapses 4. degeneration of neurons of the basal ganglia
4
a client with osteoarthritis (OA) reports experiencing painful back muscle spasms. which medication would the nurse administer? 1. tramadol 2. hyaluronate 3. diclofenac epolamine patch 4. cyclobenzaprine hydrochloride
4
a client's fasting plasma glucose levels are bing evaluated. the nurse identifies that the client is considered to be diabetic if the results are within which range? 1. 40 to 60 2. 80 to 99 3. 100 to 125 4. 126 to 140
4
after consistently obtaining a blood pressure of 140/76 for a client, which stage of hypertension will the nurse document? 1. normal 2. elevated 3. stage 1 4. stage 2
4
how would the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate? 1. red 2. black 3. green 4. yellow
4
which nursing assessment finding would indicate sufficient circulation in a 1 month old infant with newly placed casts for bilateral clubfoot (talipes equinovarus)? 1. the cast is intact and there is no drainage 2. there are no signs of pain in the extremities 3. there is range of motion in the hips and knees 4. the toes, when compressed, exhibit a quick return of circulation
4
which nursing intervention prevents foot drop in a client with osteomyelitis? 1. elevating the foot with the use of pillows 2. consistently flexing the affected extremity 3. encouraging the client to change positions 4. neutral positioning of the foot with the use of a splint
4
which response by the nurse would be the best explanation to give to a client with cellulitis of the leg who asks why bed rest has been prescribed to prevent sepsis? 1. "bed rest will decrease catabolism to promote healing at the site of injury" 2. "bed rest will lower your metabolic rate in an attempt to help reduce the fever" 3. "bed rest will reduce the energy demands on your body in the presence of infection" 4. "bed rest limits muscle contractions that may force bacteria into the bloodstream"
4
which stage of pressure ulcer would the nurse document for a client who has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue does to the underlying fascia? 1. stage I 2. stage II 3. stage III 4. unstageable
4
a client has closed fractures of the right femur and tibia with multiple soft-tissue contusions. which action would the nurse plan to take? 1. perform a neurovascular assessment of the extremity 2. reassure the client that these injuries are not that serious 3. gather equipment needed for the application of skeletal traction 4. prepare the client for a surgical reduction of the injured extremity
1
a client is scheduled for a cholecystectomy and asks the primary nurse about the function of the gallbladder. which explanation would the nurse give? 1. stores and concentrates bile 2. releases bile into the pancreatic duct 3. connects the common bile duct and the pancreas 4. controls the flow of fat through the sphincter of Oddi
1
a client reports nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. the pain occurs most often after eating ground beef, sausage, or hot dogs. which diet would the nurse instruct the client to follow? 1. low fat 2. low carbohydrate 3. soft-textured and bland 4. high protein and kilocalories
1
a client who has severe back pain is found to have a vertebral compression fracture. which cause of fracture would the nurse consider when planning interventions? 1. collapse of the vertebral bodies 2. demineralization of the spinal cord 3. wear and tear of the spinous processes 4. bulging of the spinal cord from the vertebra
1
an arrival blood gas report indicates the client's pH is 7.25, PCO2 is 35, and HCO3 is 20. which disturbance would the nurse identify based on these results? 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis
1
a school-aged child with a fracture of the femur near the epiphyseal plate is admitted to the hospital. which physiological characteristic of the femur would the nurse consider when teaching the family about the injury? 1. growth of that leg may be affected 2. risk for infection at this location is increased 3. fracture repair will necessitate prolonged traction 4. long bones contain marrow, which increases the risk for anemia
1
which statement explains why metabolic acidosis develops with kidney failure? 1. inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate 2. depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention 3. inability of the renal tubules to reabsorb water to dilute the acid contents of blood 4. impaired glomerular filtration, causing retention of sodium and metabolic waste products
1
the nurse is completing the health history of a client admitted to the hospital with osteoarthritis. which joint would the nurse expect the client to report as having been involved first? (select all that apply) 1. jips 2. knees 3. ankles 4. shoulders 5. metacarpals
1, 2
which manifestations of surgically induced hypothyroidism might the client exhibit after a thyroidectomy? (select all that apply) 1. fatigue 2. dry skin 3. insomnia 4. excitability 5. weight loss 6. intolerance to heat
1, 2
which instruction will the home health nurse include when teaching a client with peripheral artery disease? (select all that apply) 1. "avoid crossing your legs" 2. "inspect your feet daily" 3. "change positions slowly" 4. "do not use compression stockings" 5. "avoid green left vegetables in your diet"
1, 2, 4
which observation by the nurse indicates a client with pneumonia is able to use an incentive spirometer correctly? 1. records the volume of the air inspired 2. performs 10 breaths per session every hour 3. inhales air fully before inserting the mouthpiece 4. takes a long, slow, deep breath keeping the mouthpiece in place 5. exhales deep breaths with the mouthpiece in their mouth
1, 2, 4
which statement made by the nursing student about interventions that reduce the risk of pressure ulcers in a client indicates effective learning? (select all that apply) 1. "I will elevate the head of the clients bed to no more than 30 degrees" 2. "I will ensure that the client is turned and repositioned at least every 2 hours" 3. "I will advise the client to apply talc directly to the perineum" 4. "I will ensure that the client's fluid intake is 2000 to 3000 L/day" 5. "I will teach the client to remain from eating a high-protein and calorie diet"
1, 2, 4
which clinical indicators would the nurse expect to find when assessing a client with Parkinson disease? (select all that apply) 1. resting tremors 2. flattened affect 3. muscle flaccidity 4. tonic-clonic seizures 5. slow voluntary movements
1, 2, 5
which effect does increased parathyroid hormone have on bones and electrolytes? (select all that apply) 1. increased bone breakdown 2. increased serum calcium levels 3. increased sodium and phosphorus excretion 4. increased absorption of calcium and phosphorus 5. increased net release of calcium and phosphorus
1, 2, 5
which manifestation would the nurse include when teaching a client about ketoacidosis? (select all that apply) 1. confusion 2. hyperactivity 3. excessive thirst 4. fruity-scented breath 5. decreased urinary output
1, 3, 4
which statement made by the client about sleeping positions to follow to prevent pressure ulcers indicates effective learning? (select all that apply) 1. "I should use pressure-relieving pads" 2. "I should place a rubber ring under the sacral area" 3. "I should place pillows between two bony surfaces" 4. "I should keep the head of the bed elevate above 30 degrees" 5. "I should keep my heels off the bed surface using a bed pillow under the ankles"
1, 3, 5
list in order of priority the techniques the nurse would use to assess a child's abdomen with suspected appendicitis? 1. ask where it hurts 2. assess the abdomen by touch 3. auscultate for bowel sounds 4. warm the stethoscope's diaphragm 5. visually examine the abdomen
1, 5, 4, 3, 2
which age-related skin change occurs in older clients and increases their potential for developing pressure ulcers? 1. atrophy of the sweat glands 2. decreased subcutaneous fat 3. stiffening of the collagen fibers 4. degeneration of the electric fibers
2
which documented condition will the nurse observe in the electronic medical record of a client presenting with red, inflamed skin covered with papule, vesicles, and bulbar from a type IV hypersensitivity reaction? 1. allergic rhinitis 2. contact dermatitis 3. good pasture syndrome 4. systemic lupus erythematosus (SLE)
2
which education would the nurse provide the parent of an infant with pyloric stenosis? 1. it is unlikely that surgery will be necessary 2. this is a condition with an excellent prognosis 3. this condition results from an error of metabolism 4. special feedings will be needed for a few weeks after surgery
2
which information would be included in the teaching plan for the older adult client with peptic ulcer disease who is taking an antacid and sucralfate? 1. antacids should be taken 30 minutes before a meal 2. sucralfate should be taken on an empty stomach 1 hour before meals 3. sucralfate is prescribed for the ling-term maintenance of peptic ulcer disease 4. sodium bicarbonate is an inexpensive OTC antacid with few adverse effects
2
which intervention would the nurse provide a 3 month old infant hospitalized with respiratory syncytial virus (RSV)? 1. adminsitering an antiviral agent 2. clustering care to conserve energy 3. administering a bronchodilator every four hours 4. providing an antitussive agent whenever necessary
2
which laboratory test change leads the nurse to determine that the lactulose administered to a client with cirrhosis of the liver is effective? 1. decreased amylase 2. decreased ammonia 3. increased potassium 4. increased hemoglobin
2
which nursing intervention assists in decreasing the potential occurrence of pressure ulcers when providing care for a client with quadriplegia? 1. avoid massaging the client's legs 2. frequently reposition the client on a scheduled basis 3. increase the fiber content in the client's foos 4. encourage the client to participate in weight-bearing exercises
2
which pathophysiological rationale explains why a client who is 4 days post abdominal surgery has not passed flatus and has hypoactive bowel sounds and why a paralytic ileus is suspected of developing? 1. decreased blood supply 2. impaired neural functioning 3. perforation of the bowel wall 4. obstruction of the bowel lumen
2
which physiological activity is associated with the "proliferative phase" of normal wound healing? 1. white blood cells migrate into the wound 2. epithelial cells grow over the granulation tissue 3. scar tissue gradually becomes thinner and pale 4. vasodilation occurs with increased capillary permeability
2
which response would the nurse give to a client with tuberculosis who asks about the communicability of the disease? 1. "tuberculosis is not communicable at this time" 2. "untreated active tuberculosis is communicable" 3. "tuberculosis is communicable during the primary stage" 4. "with the newer long-term therapies, tuberculosis is not communicable"
2
which assessment finding indicates to the nurse that a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen is retaining carbon dioxide (CO2)? 1. anxiety 2. drowsiness 3. irregular pulse 4. mental confusion 5. increased respirations
2, 3, 4
which clinical manifestation would lead the nurse to contact the health care provider regarding the potential development of acute osteomyelitis? (select all that apply) 1. presence of a foot ulcer 2. temperature of 102 F 3. erythema of the affected area 4. tenderness of the affected area 5. drainage from the affected area
2, 3, 4
which sign or symptom would the nurse expect when assessing a client with type 1 diabetes who is experiencing hypoglycemia? (select all that apply) 1. vomiting 2. headache 3. tachycardia 4. cool, clammy skin 5. increased respirations
2, 3, 4
when monitoring a client for hyponatremia, which assessment findings would the nurse consider significant? (select all that apply) 1. thirst 2. seizures 3. erythema 4. confusion 5. constipation
2, 4
which information obtained by the nurse about a client would represent a risk factor for the client's admission diagnosis of hypertension? (select all that apply) 1. daily use of 1 aspirin 2. occasional cocaine use 3. reduced hemoglobin level 4. African american/black heritage 5. increased high-density lipoprotein (HDL)
2, 4
the nurse is providing discharge instructions to a client diagnosed with cirrhosis and varies. which information would the nurse include int the teaching session? (select all that apply) 1. adhering to a low-carbohydrate diet 2. avoiding aspirin and aspirin-contains products 3. limiting alcohol consumption to two drinks weekly 4. avoiding acetaminophen and products containing acetaminophen 5. avoiding coughing, sneezing, and straining to have a bowel movement
2, 4, 5
the nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89, PCO2 35, and pH of 7.37. these findings indicate that the client is experiencing which condition? 1. respiratory alkalosis 2. poor oxygen perfusion 3. normal acid-base balance 4. compensated metabolic acidosis
3
which pain description would the nurse expect a client to report when describing pain associated with a suspected duodenal peptic ulcer? 1. an ache radiating to McBurney point 2. an intermittent, colicky right-flank pain 3, a gnawing sensation in the epigastric area 4. a generalized abdominal pain intensified by movement
3
the nurse provides education for a client with cirrhosis of the liver who has a prolonged prothrombin time and a low platelet count. a regular diet is prescribed. which instruction would the nurse include in the teaching? 1. avoid foods high in phytonadione 2. check the pulse several times a day 3. drink a glass o milk when taking aspirin 4. report signs of bleeding no matter how slight
4
which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? 1. serum sodium of 139 2. serum chloride of 100 3. serum calcium 10.2 4. serum potassium of 7.2
4
which etiology is the primary case of otitis media in young children? 1. sinusitis 2. recurrent tonsillitis 3. an inflamed mastoid process 4. an obstructed eustachian tube
4
which information provides the rationale for a nurse writing a goal of preventing renal calculi in a care plan for a client who has paraplegia? 1. high fluid volume intake 2. increased calcium intake 3. inadequate kidney function 4. accelerated bone demineralization
4
which information would the nurse provide to a client with benign prostatic hyperplasia after the health care provider prescribes finasteride? 1. male pattern baldness can occur 2. results can be expected in 4 to 6 weeks 3. the medication relaxes the muscles in the bladder neck 4. a condom should be worn during intercourse with a pregnant female
4
which nursing action is most important for a client with urinary retention related to benign prostatic hyperplasia who has a secondary diagnosis of delirium related to urosepsis and a prescription for the insertion of an indwelling urinary retention catheter? 1. secure a prescription for wrist restraints 2. orient the client to time, place, and person 3. involve family members in the client's care 4. determine whether any unsafe behavior patterns exist
4
which parent education would the nurse provide for a 4 month old infant with a newly diagnosed acute otitis media and fever? 1. "anti-inflammatory medications are recommended for this condition" 2. "typically antiviral medications re given to treat acute otitis media" 3. "current practice is to wait 72 hours to see whether the condition resolves" 4. "antibiotics are recommended for infants younger than 6 months with acute otitis media"
4
which plan of care would the true provide for a newborn with hypospadias? 1. preparing the infant for insertion of a cystostomy tube 2. explains to the parents the genetic basis for the defect 3. keeping the infant's penis wrapped with petroleum gauze 4. giving the parents reasons why circumcision should not be performed
4
which prescription would the nurse question when a client's serum sodium is 123 mEq?L? 1. add table salt to each meal 2. fluid restriction of 100 mL per day 3. assess neurological status every 2 hours 4. provide 0.45% sodium chloride (NaCL) intravenously at 125 mL/h
4
which type of hepatitis is commonly spread by consuming contaminated food and water or by fecal contamination? (select all that apply) 1. hepatitis A 2. hepatitis B 3. hepatitis C 4. hepatitis D 5. hepatitis E
1, 5
which nursing action is the priority for a client who has a serum potassium level of 6.7? 1. monitor for cardiac dysrhythmias 2. inquire about changes in bowel patterns 3. assess for leg muscle twitching or weakness 4. assess for signs and symptoms of dehydration
1
an older client with shortness of breath is admitted to the hospital. the medical history reveals a diagnosis of pneumonia 3 days ago. which vital sign assessment would be seen as a sign that the client needs immediate medical attention? 1. oxygen saturation: 89% 2. body temperature: 101 F 3. blood pressureL 130/80 4. respiratory rate: 26
1
the nurse teaches a client who is concerned about hepatitis transmission routes. which type of hepatitis spreads more frequently through food? 1. A 2. B 3. C 4. D
1
the pathophysiology of celiac disease is characterized by which description? 1. inability to metabolize gluten 2. absence of the enzyme phenylalanine 3. excessive amount of salt in the sweat glands 4. increase in the viscosity of mucous secretions
1
which food selections by a client with celiac disease indicate the nurse's dietary teaching was successful? (select all that apply) 1. green beans 2. baked potato 3. noodle pudding 4. turkey sandwich 5. whole-wheat cereal
1, 2
which assessment findings are systemic manifestations of acute osteomyelitis? (select all that apply) 1. malaise 2. restlessness 3. night sweats 4. warmth at the infection site 5. swelling at the infection site
1, 2, 3
which clinical manifestation of a UTI would the nurse teach to a male client with a history of recurrent urinary tract infections (UTIs) when preparing for discharge after a ureterolithotomy? 1. urgency or frequency of urination 2. an increase of ketones in the urine 3. the inability to maintain an erection 4. pain radiating to the external genitalia
1
which complication would the nurse be concerned about if there is removal of the parathyroid glands during a thyroidectomy? 1. tetany 2. myxedema 3. hypovolemic shock 4. adrenocortical stimulation
1
which medication is classified as an H2 receptor antagonist? (select all that apply) 1. nizatidine 2. ranitidine 3. fmaotidine 4. lansoprazole 5. metoclopramide
1, 2, 3
which feature is associated with the "maturation phase" of normal wound healing? 1. the scar is from and inelastic on palpation 2. fibrin strands form a scaffold or framework 3. white blood cells migrate into the wound 4. epithelial cells are grown over the granulation tissue bed
1
which food would the nurse encourage a client to eat while receiving treatment to prevent hypokalemia? 1. broccoli 2. oatmeal 3. fried rice 4. canned carrots
1
on a routine visit to the pediatric clinic, the parent of a 6 week old infant tells the nurse that their baby has the "cutest little folds on their legs, two on one side and three on the other." which condition would the nurse associated with this finding? 1. hyp dysplasia 2. neonatal obesity 3. slipped epiphysis 4. talipes equinovarus
1
the nurse is assessing female clients and identifies that which client has the greatest risk of developing gallbladder disease? 1. older than age 40 and obese 2. older than age 40 with a low serum cholesterol level 3. less than 40 years of age with a history of high fat intake 4. less than 40 years of age with a family history of gallstones
1
the nurse is caring for a 4 yo child who has been hospitalized with an acute asthma exacerbation. which assessment finding would require immediate action by the nurse? 1. diminished breath sounds 2. pulse rate of 110 beats per minute 3. pulse oximetry reading of 95% 4. respiratory rate of 24 breaths per minute
1
the nurse is caring for a school-aged child with cystic fibrosis. which pathophysiologic factor has the greatest effect on the child's heath status? 1. extremely thick mucus causing obstructed airways 2. acute inflammation of the lung parenchyma 3. endocrine glands secreting increased levels of hormones 4. increased irritability of the airways resulting gin obstruction
1
which statement indicates the patient understands the origin of hepatitis C? 1. "you can catch it while you're getting a tattoo" 2. "you're more likely to get it in crowded living conditions" 3. "the disease is passed from person to person by casual contact" 4. "people working at restaurants can give it to you if they don't wash their hands"
1
which change would the nurse assess for in a client who sustained skin injuries 3 days ago? (select all that apply) 1. local edema 2. erythema 3. pale color of scar tissue 4. formation of scar tissue 5. red colored graduation tissue
1, 2
which clinical manifestation would the nurse anticipate when assessing a client with hypothyroidism? (select all that apply) 1. dry skin 2. brittle hair 3. weight loss 4. resting tremors 5. heat intolerance
1, 2
the nurse is obtaining a health history from a client with a diagnosis of peptic ulcer disease. the nurse identifies a possible contributory risk factor when the client makes which statement? 1. "my blood type is A positive" 2. "I smoke a pack of cigarettes a day" 3. "I have been overweight most of my life" 4. "my blood pressure has been high lately"
2
the nurse is providing preoperative teaching to a client who is scheduled for abdominal surgery. the client is fidgeting, slightly diaphoretic, and asking simple questions about information that was already provided during the education session. which initial step would the nurse take? 1. repeat the information, speaking slowly and distinctly 2. reduce the client's level of anxiety 3. teach the client about measures to lessen preoperative anxiety 4. ask the client to verbalize concerns and questions
2
the nurse reviews the laboratory results of a client with acute pancreatitis. which test is significant in determine the client's response to treatment? 1. platelet count 2. amylase level 3. red blood cell count 4. erythrocyte sedimentation rate
2
when a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia? 1. giving influenza vaccine to the client 2. having suction available during meals 3. assisting the client to take deep breaths 4. teaching about incentive spirometer use
2
when auscultating the mid-abdomen of a client with an intestinal obstruction in the descending colon, which type of sound would the nurse expect to hear? 1. tympana 2. borborygmi 3. abdominal bruit 4. pleural friction rub
2
which type of hepatitis develops into a chronic form of the disease? (select all that apply) 1. hepatitis A 2. hepatitis B 3. hepatitis C 4. hepatitis D 5. hepatitis E
2, 3, 4
which assessment would the nurse include during routine visits for an infant being treated for talipes equinovarus (clubfoot) who has a cast change every 2 to 3 weeks? (select all that apply) 1. pedal pulses of both feet 2. range of motion of the foot in the cast 3. color of the toes of the foot in the cast 4. movement of the toes of the foot in the cast 5. knee flexion and extension of the affected leg
3, 4
diagnosed with chronic obstructive pulmonary disease (COPD), a 50 yo client's clinical data after treatment is: heart rate of 100, BP 138/82, RR 32, temp 98.2F, and O2 80%. which vital sign obtained by the nurse indicates a positive outcome? (select all that apply) 1. radial pulse: 70 2. temp: 98.6F 3. RR: 14 4. BP 110/70 5> O2: 92%
3, 4, 5
the nurse is caring for a client with a bowel obstruction. which assessment findings indicate the possible onset of peritonitis? (select all that apply) 1. diarrhea 2. bradycardia 3. rebound tenderness 4. diminished bowel sounds 5. rigid, boardlike abdomen
3, 4, 5
the nurse is caring fro a client with gastrointestinal reflux disease (GERD). which information would the nurse provide the client to prevent worsening of the disorder? (select all that apply) 1. eat a snack before bed 2. include vigorous exercise 3. wear loos-fitting clothing 4. begin a weight-loss program 5. sleep with head of bed elevated
3, 4, 5
which client would benefit from the administration of prophylactic antibiotics? (select all that apply) 1. chicken pox infection 2. fever of unknown origin 3. preoperative hip replacement 4. congenital bicuspid aortic valve 5. current chemotherapy treatment
3, 4, 5
the nurse teaches the parents of a child with celiac disease about foods that should be eliminated from the diet. which foods do the parents name that indicate to the nurse that the teaching has been understood? (select all that apply) 1. milk 2. cheese 3. oatmeal 4. rice cakes 5. corn on the cob 6. whole wheat bread
3, 6