HESI FINAL (Select All That Apply)

A nurse is caring for a client with a tentative diagnosis of pheochromocytoma who is receiving chlorpromazine (Thorazine). A 24-hour urine specimen to assess the presence of vanillylmandelic acid (VMA) is prescribed to assist in the confirmation of the diagnosis. What information should the nurse include in the client teaching regarding this test? Select all that apply.

All urine excreted over the 24-hour period must be saved and refrigerated. Avoid coffee, chocolate, and citrus fruit for three days before and during the test.

A client with metastatic breast cancer is started on a multiple drug regimen that includes docetaxel (Taxotere). The nurse assesses the client for which nontherapeutic effects of docetaxel? Select all that apply.

Alopecia Febrile neutropenia Hypersensitivity reaction

A client diagnosed with bone cancer of the leg will receive radiation therapy as part of the treatment plan. The client has voiced concern about the side effects of the radiation treatments. The nurse will prepare the patient for which major side effects of radiation therapy? Select all that apply.

Altered taste sensations Fatigue

The nurse is assessing a client with hyperthyroidism. For which signs and symptoms should the nurse assess the client? Select all that apply.

Amenorrhea Flushed appearance Short attention span

Discharge instructions for the client diagnosed with cirrhosis with varices should include information about the importance of: Select all that apply.

Avoiding aspirin and aspirin containing products Avoiding acetaminophen and products containing acetaminophen Avoiding coughing, sneezing, and straining to have a bowel movement

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

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

A nurse assesses a client's intravenous site. What clinical finding leads the nurse to conclude that the intravenous (IV) site has been infiltrated? Select all that apply.

Coolness of skin near the insertion site, Swelling around the insertion site Cessation in flow of solution

A nurse identifies that a client receiving chemotherapy has lost weight. What are appropriate nursing interventions for this client? Select all that apply.

Encouraging the intake of preferred foods Promoting the intake of small, frequent meals Administering prescribed antiemetics before meals

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

Irritability Heart palpitations

A nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia should the nurse assess the newborn? Select all that apply.

Irritability Hypotonia Ineffective sucking

A client is admitted with the diagnosis of acute pancreatitis. For which clinical manifestations should a nurse assess the client? Select all that apply.

Jaundice Acute pain Increased amylase

Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson disease. The nurse assesses for which adverse responses that are associated with this medication? Select all that apply.

Nausea Emotional changes

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

Obese trunk Sleep disturbance Thin arms and legs

A nurse is assessing an older adult client. Which clinical findings are expected responses to the aging process? Select all that apply.

Slowed neurological responses Forgetfulness about recent events Reduced ability to maintain an erection

A nurse is assessing a male newborn. Which characteristics should alert the nurse to conclude that the newborn is a preterm infant? Select all that apply.

Small breast buds Wrinkled thin skin Pinnae that remain flat when folded

A nurse is teaching an adult health and wellness class about bladder cancer. The nurse informs the class participants that which activities put a person at risk for bladder cancer? Select all that apply.

Smoking two packs of cigarettes a day Working with dyes and ink every day

Which of the following signs are indications of hydration status during a sickle cell crisis? Select all that apply.

Turgor of tissue Texture of mucous membranes

Which physiological responses should a nurse expect when assessing a client with hyperthyroidism? Select all that apply.

Blurred vision Increased appetite Widened pulse pressure

A nurse is estimating a newborn's gestational age. What parameters should the nurse assess? Select all that apply.

Breast size Genital development

A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? Select all that apply.

Coughing or sneezing Straining when having a bowel movement

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply.

Crackles Atelectasis Hypoxemia Severe dyspnea

A client had thoracic surgery. The nurse should monitor for what clinical manifestations that may indicate acute pulmonary edema? Select all that apply.

Crackles Cyanosis Frothy sputum

A client has left ventricular heart failure. For which clinical indicators should the nurse assess the client? Select all that apply.

Crackles Dyspnea on exertion

The nurse provides care to the client with Parkinson disease, who experiences freezing of gait (FOG), by: select all that apply

Cuing the client with rhythmic clapping Encouraging the client to step over an imaginary line

The nurse is caring for a client who is experiencing cardiogenic shock. Which clinical findings support this diagnosis? Select all that apply.

Dyspnea Diaphoresis Tachycardia

Following a major abdominal surgery, a client has a nasogastric tube attached to continuous low suction. The nurse caring for the client postoperatively monitors the client for what signs of hypokalemia? Select all that apply.

Dysrhythmias Muscle weakness

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? Select all that apply.

Eat foods high in vitamin C. Take your temperature daily. Balance periods of rest and activity.

The nurse is assessing a client with hyperthyroidism. Which clinical indicators are consistent with this diagnosis? Select all that apply.

Emotional lability Dyspnea on exertion Hyperactive deep tendon reflexes

A nurse is caring for an older client who had non-insulin dependent diabetes for 15 years that progressed to insulin dependent diabetes 2 years ago. What common complications of diabetes should the nurse assess for when examining this client? Select all that apply.

Leg ulcers Loss of visual acuity Prolonged capillary refill in the toes Decreased sensation in the lower extremities

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

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

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

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

When receiving hemodialysis, the complication of the removal of too much sodium may occur. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply.

Muscle cramps Extreme fatigue

A client is receiving total parenteral nutrition solution. Potassium has not been added to the solution. The nurse monitors the client for which signs of hypokalemia? Select all that apply.

Muscle weakness Cardiac dysrhythmias

A nurse is teaching a female client about using oral contraceptives and when to report complications. What clinical findings should alert the client to stop taking the contraceptive and notify the health care provider immediately? Select all that apply.

Headaches/Visual disturbances.

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

Obese trunk Sleep disturbance Thin arms and legs

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

Hirsutism Buffalo hump

The laboratory results of a woman in labor indicate the presence of cocaine and alcohol. Which characteristics should cause the nurse to recognize fetal alcohol syndrome (FAS) in the newborn? Select all that apply.

Hypotonia Hypoplastic maxilla Small, upturned nose

Which actions should the nurse include when teaching a client about self-administration of a gastrostomy tube feeding? Select all that apply.

Instill water after the feeding Re-instill gastric contents removed after assessing for residual gastric contents

A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply.

On admission to the hospital Before transfer to a rehabilitation facility

A client who is at risk for seizures as a result of severe preeclampsia is receiving an IV infusion of magnesium sulfate. What findings cause the nurse to determine that the client is showing signs of magnesium sulfate toxicity? Select all that apply.

Respirations of 10/min Loss of patellar reflexes

All women of childbearing age are advised to include at least 400 micrograms of folic acid in the daily diet to lessen the risk of neural tube defects in pregnancy. What should the nurse recommend to meet the recommendation? Select all that apply.

Vitamin B9/Legumes, dark-green leafy vegetables, and citrus fruits.

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply.

Vomiting Muscle weakness Irregular heart rate

A client who sustained serious burns now has a stress ulcer. When caring for this client, what clinical indicators should the nurse immediately report to the health care provider? Select all that apply.

Weakness Diaphoresis Tachycardia Cold extremities

The nurse is providing instructions about foot care for a client with diabetes mellitus. What should the nurse include in the instructions? Select all that apply.

Wear shoes when out of bed. Dry between the toes after bathing.

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.

Bradycardia Hypotension Bladder dysfunction

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

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

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

Oliguria Seizures Vomiting

Considerations when caring for a client with a total hip replacement should include which of the following? Select all that apply.

Pain control should include regularly scheduled analgesics and may necessitate use of as needed medications as well. Frequent neurovascular assessment should be done distal to the surgical site and compared with the unaffected side. When turning, client should be log rolled to prevent leg from falling forward or backward.

A nurse is assessing a client who is being admitted for surgical repair of a rectocele. What signs or symptoms does the nurse expect the client to report? Select all that apply.

Painful intercourse/Bearing-down sensations.

A 32-year-old woman is admitted to the unit with a history of fibroids and menorrhagia. Which findings does the nurse expect to encounter during assessment of the client? Select all that apply.

Pale mucous membranes/ Difficulty emptying the bladder.

Which responses should a nurse expect a client experiencing hypoglycemia to exhibit? Select all that apply.

Palpitations Tachycardia Nervousness

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

Palpitations Diaphoresis Slurred speech

A client is admitted to the hospital with a diagnosis of chronic kidney disease. Which responses should the nurse expect the client to exhibit? Select all that apply.

Paresthesia Hypertension

Methods of relieving back pain are explained during a childbirth class. What activities identified by the client permit the nurse to conclude that the teaching has been understood? Select all that apply.

Pelvic rocking/Forward tilting/Sacral pressure.

A nurse teaches the mother of a newborn with phenylketonuria (PKU) why it is important to restrict the amount of phenylalanine in her infant's formula. Because all proteins contain this essential amino acid, the nurse suggests appropriate formulas. Which formulas are safe for this infant? Select all that apply.

Phenex Lofenalac

A nurse is teaching a preoperative client about postoperative breathing exercises. What information should the nurse include? Select all that apply.

Place a hand on the abdomen while feeling it rise Hold the breath for several seconds at the height of inspiration

The menu for a client with malabsorption syndrome must be limited because of a sensitivity to gluten. Which foods cannot be served to this client? Select all that apply.

Roast beef sandwich Chicken noodle soup Spaghetti and meatballs

A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? Select all that apply.

Scaly lesions Pruritic lesions Reddened papules

A nurse is caring for a client who is receiving total parenteral nutrition. Which responses indicate that the client is experiencing hyperglycemia? Select all that apply.

Polyuria Polydipsia

A health care provider orders a contraction stress test (CST) for a client whose nonstress test (NST) was nonreactive. Which maternal complications should prompt the nurse to question the order? Select all that apply.

Preterm labor Incompetent cervix Premature rupture of membranes

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

Lability of mood Slow wound healing

A pregnant client with a history of rheumatic heart disease since childhood is concerned about the birth of her baby and asks what to expect. What should the nurse explain about the birth? Select all that apply.

Labor may be induced. Birth may be vacuum extraction assisted. Regional anesthesia may be administered.

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

Leg ulcers Loss of visual acuity Thick, yellow toenails Decreased sensation in the feet

A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? Select all that apply.

Lethargy Muscle twitching

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

Weight loss Tachycardia Restlessness Exophthalmos

A nurse is caring for a client with hepatic cirrhosis. Which elements are important to include in this client's diet? Select all that apply.

Low protein Low sodium High vitamins

A woman at 40 weeks' gestation is admitted in active labor. After appropriate progress of her labor, the woman asks for and receives epidural analgesia. Once the epidural catheter has been inserted, which nursing assessments and interventions should be performed? Select all that apply.

Maintaining intravenous fluid administration Having oxygen available in case of hypotension Checking the bladder for distention every 2 hours Monitoring fetal heart rate and labor progress per hospital protocol

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

Nuchal rigidity Pharyngeal spasm

A nurse is caring for a female client who is receiving rifampin (Rifadin) for tuberculosis. Which statements indicate that the client understands the teaching about rifampin? Select all that apply.

"This drug may be hard on my liver so I must avoid alcoholic drinks while taking it." This drug may reduce the effectiveness of the oral contraceptive I am taking." My health care provider must be called immediately if my eyes and skin become yellow."

Which clinical indicators identified by the nurse support the probable presence of a fecal impaction in a client? Select all that apply.

Abdominal cramps Fecal liquid seepage Hyperactive bowel sounds

A nurse inserts a nasogastric tube into a preterm infant's esophagus for feedings. Which assessment findings signify correct placement of the tube? Select all that apply.

Aspiration produces a small quantity of light-yellow or light-green liquid. Testing of the aspirate with the use of a Nitrazine strip reveals that the gastric fluid is acidic

Which of the following variables are scored on a biophysical profile? Select all that apply

Fetal tone Fetal movement Amniotic fluid index Fetal breathing movements

Which factors should the nurse identify that can precipitate hyponatremia? Select all that apply.

Gastrointestinal (GI) suction Diuretic therapy Continuous bladder irrigation

A nurse is assisting a client to plan a therapeutic diet that is high in vitamin C. What excellent sources of vitamin C should be included in the plan? Select all that apply.

Oranges Broccoli Strawberries

Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply.

Diarrhea Weight loss

What clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply.

Edema Dyspnea

Fludrocortisone (Florinef) is prescribed for a client with adrenal insufficiency. Which responses to the medication should the nurse teach the client to report? Select all that apply.

Edema Rapid weight gain

A nurse provides instruction to a client who was treated for renal colic as a result of uric acid stones. What should the nurse include in the teaching plan? Select all that apply.

Eliminate organ meats from diet. Drink two glasses of water at bedtime. Increase fluid intake to three quarts daily.

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

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

A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. What areas of paralysis should the nurse expect the client to exhibit? Select all that apply.

Left leg Left arm

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply.

Leg cramps, Muscle weakness

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

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

A nurse is caring for a client with a ureteral calculus. Which are the most important nursing actions? Select all that apply.

Monitoring intake and output Straining the urine at each voiding Administering the prescribed analgesic

A primigravida at 34 weeks' gestation tells the nurse that she is beginning to experience some lower back pain. What should the nurse recommend that the client do? Select all that apply.

Wear low-heeled shoes. Perform pelvic tilt exercises several times a day.

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which manifestations of excessive levels of ADH should the nurse assess the client? Select all that apply.

Weight gain Hyponatremia

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

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

For which clinical indicators should the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice? Select all that apply.

Dark urine Yellow skin Clay-colored stool

A nurse suspects that a newborn's mother had rubella during the first trimester of pregnancy. Which newborn problems support this assumption? Select all that apply.

Deafness (sordera) Cardiac anomalies

A client's serum potassium level is below the expected range. Which clinical indicators should the nurse determine are consistent with hypokalemia? Select all that apply.

Decreased heart rate Peripheral paresthesia Decreased bowel sounds

A nurse assessing a newborn identifies several characteristics of Turner syndrome. Which features did the nurse observe? Select all that apply.

Webbed neck Female sex organs Widely spaced nipples

The nurse is caring for a 76-year-old obese client with a history of epigastric distress, esophageal burning, binge drinking, and frequent episodes of bronchitis. A diagnosis of hiatal hernia is made. Which health problems most likely contributed to the development of the hiatal hernia? Select all that apply.

Aging Obesity Alcoholism

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

Backache Shivering

A nurse is teaching a client who is taking a loop diuretic (e.g., furosemide [Lasix]) about foods that are high in potassium. Which foods should the nurse emphasize? Select all that apply.

Bananas Beef stew Baked potatoes

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

Blood in the stool Ringing in the ears

A nurse is counseling a client who is at risk for developing osteoporosis. Which foods should the nurse recommend? Select all that apply.

Chicken breasts Broiled beef steak

Which nursing interventions require a nurse to wear gloves? Select all that apply.

Cleaning a newborn immediately after delivery Emptying a portable wound drainage system

A nurse is teaching a client about a sodium-restricted diet. What foods should the nurse encourage the client to avoid? Select all that apply.

Cold cuts Processed foods

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

Confusion Muscle weakness

A client is brought into the emergency department with complaints of chest pain. What are possible causes for the client's chest pain? Select all that apply.

Costochondritis Pneumonia, Pleuris Myocardial infarction

The neurologic assessment of a client who had a craniotomy includes the Glasgow Coma Scale. What does the nurse evaluate to assess the client's score on the Glasgow Coma Scale? Select all that apply.

Degree of purposeful movement by the client Appropriateness of the client's verbal responses Stimulus necessary to cause the client's eyes to open

A client with acute renal failure moves into the diuretic phase after one week of therapy. For which signs during this phase should the nurse assess the client? Select all that apply.

Dehydration Hypovolemia

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply.

Dependent edema Swollen hands and fingers Right upper quadrant discomfort

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

Dependent edema Distended abdomen Polyuria at night

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

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

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

Diaphoresis Weight loss Protruding eyes

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply.

Diminished sensation of pain Impaired hearing of high-frequency sounds

A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. For which clinical indicators should the nurse closely observe the client? Select all that apply.

Drowsiness Mental confusion

The nurse is providing postoperative care for a client who has received a prescription for nalbuphine (Nubain) for pain. For which side effects or adverse reactions should the nurse assess this client after administering this medication? Select all that apply.

Dry mouth Palpitations Constipation Orthostatic hypotension

A nurse is caring for several postoperative clients. For what clinical manifestations of a pulmonary embolus should the nurse monitor these clients? Select all that apply.

Dyspnea Hemoptysis Feeling of impending doom

Fludrocortisone (Florinef) is prescribed for a client with adrenal insufficiency. Which responses to the medication should the nurse teach the client to report? Select all that apply.

Edema Rapid weight gain

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

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

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

Fatigue Dry skin Progressive weight gain

The nurse is caring for a client with type 1 diabetes. For which signs or symptoms of insulin reaction should the nurse particularly be observant? Select all that apply.

Headache Diaphoresis

A nurse is assessing a pregnant 16-year-old client. What factors that may affect the outcome of the pregnancy should the nurse consider? Select all that apply.

Inappropriate dietary choices/Immature reproductive system/Underdeveloped musculoskeletal system.

Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply.

Irritability High-pitched cry Ineffective feeding behavior

After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which signs met the criteria of 2 points? Select all that apply.

Reflex irritability: cry Respiratory rate: good cry Heart rate: 110 beats/min

A client has rotator cuff surgery. What should be included when the nurse performs a neurovascular assessment of the affected extremity immediately after surgery? Select all that apply.

Skin color Movement of the hand Sensations in the extremity

A person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestations of hypothermia does the nurse expect? Select all that apply.

Stupor Paresthesia in affected body parts

The nurse is caring for a client that has undergone a total hip replacement. The nurse recognizes which clinical manifestations indicate a pulmonary embolism. Select all that apply.

Unilateral chest pain Sudden onset of shortness of breath

Optimal teaching for the client with multiple sclerosis (MS) who is experiencing urinary retention includes: select all that apply

Using Crede's maneuver Monitoring for and reporting signs of urinary tract infection

A nurse is teaching an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply.

What is diabetes?" Can you tell me how the glucose monitor works?"

The mother of an 8-month-old who was recently diagnosed with celiac disease asked for information as to what foods contain gluten. Select all that apply

Wheat Oatmeal Cream of Wheat

An estrogen-progestin oral contraceptive is prescribed for a client. Which adverse effects should the nurse teach the client to report to the health care provider? Select all that apply.

Chest pain/ Breast soreness/ Calf tenderness.

Which response should the nurse expect when assessing a client who is dehydrated? Select all that apply.

Confusion Sunken eyeballs Decreased blood pressure

A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? Select all that apply.

Coughing Orthopnea Diaphoresis

The nurse is creating a discharge teaching plan for a client that had a subtotal gastrectomy. The nurse should include what instructions about minimizing dumping syndrome? Select all that apply.

Eat small frequent meals Lie down for one hour after eating

A client on a low-residue diet asks the nurse about foods that must be avoided. Which foods should the nurse instruct the client to avoid? Select all that apply.

Fresh fruit Whole wheat bread

The nurse is teaching a diabetic client about the advantages of using an insulin pump. What information should the nurse include? Select all that apply.

can improve A1c levels Clients can exercise without eating more carbohydrates

Which clinical manifestations does a nurse expect that a client with renal calculi might report? Select all that apply.

Blood in the urine Frequency and urgency of urination

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? Select all that apply.

Boiled spinach Sweet potatoes

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. The nurse determines that the client understands the dietary instructions when the client identifies the following foods. Select all that apply.

Chicken broth Enriched whole milk Red meats, such as beef Liver and other glandular organ meats

A nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction? Select all that apply.

Dry cough Singed nasal hair Hoarse quality to the voice

A nurse is counseling an obese postmenopausal client how to prevent bone loss. Which statements indicate understanding of the strategies to prevent bone loss? Select all that apply.

I should take 1200 mg of calcium every day/ Going to an aerobics class three times a week will help my bones.

A nurse is caring for a client after a thyroidectomy. For which signs of thyroid storm should the client be monitored? Select all that apply.

Increased heart rate Increased temperature

A toddler is being discharged after myringotomy. What potential complications should the nurse teach the child's parents to report? Select all that apply.

Increased pain Lack of drainage

Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply.

Increased sensitivity to glare Diminished sensation of pain

The nurse is giving discharge instructions to the parents of a toddler who had a myringotomy. The nurse tells them about which most common complications associated with this surgery? Select all that apply.

Lack of drainage Increasing ear pain

A client is diagnosed with acute lymphoid leukemia and is receiving chemotherapy. The nurse should monitor what thrombocytopenic side effects of chemotherapy? Select all that apply.

Melena Purpura Hematuria

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

Raisins Spinach

A 37-year-old client with type 1 diabetes and good glycemic control is pregnant for the third time. Her first child is 4 years old, and her second pregnancy resulted in a stillbirth. She is seen in the antepartum testing unit for a nonstress test (NST) at 33 weeks' gestation. What are the primary risk factors in the client's history that indicate a need for the NST? Select all that apply.

The risk for placental insufficiency A history of stillbirth from her last pregnancy Maternal history of hypertension

A client has a diagnosis of an unruptured tubal pregnancy. Which assessment findings correlate with this diagnosis? Select all that apply.

Unilateral abdominal pain History of a sexually transmitted infection

A client on prolonged cortisone therapy for adrenal insufficiency is being discharged. Which side effects should the nurse teach the client and family to expect? Select all that apply.

Weakness Moon face Weight gain

A client is in the intensive care unit after sustaining a T2 spinal cord injury. Which priority interventions should the nurse include in the client's plan of care? Select all that apply.

Assessing for respiratory complications Monitoring and maintaining blood pressure

A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. What locations on the client's body should the nurse assess? Select all that apply.

Nail beds Conjunctivae Palms of hands

During the initial assessment of a newborn the nurse suspects a congenital heart defect. Which clinical manifestations support this suspicion? Select all that apply.

Nasal flaring Sternal retractions Grunting respirations

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

Nausea Yellow vision Irregular pulse

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

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

A nurse is trying to determine whether a pregnant woman's membranes have ruptured. What findings support the conclusion that they have ruptured? Select all that apply.

Nitrazine paper turns blue on contact with the fluid. Microscopic examination of the fluid reveals ferning.

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

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

A nurse is performing the history and physical examination of a client with Parkinson disease. Which assessments identified by the nurse support this diagnosis? Select all that apply.

Nonintention tremors Masklike facial expression Low-pitched monotonous voice

A client has a diagnosis of hemorrhoids. Which signs and symptoms does the nurse expect the client to report? Select all that apply.

Anal itching Blood in stool Rectal pressure Pain when defecating

A nurse is reviewing the history, physical examination, and diagnostic test results of a client with colitis. What clinical findings are associated with this disorder? Select all that apply.

Anemia Diarrhea Abdominal cramps

A client with end-stage renal disease is hospitalized. For what signs and symptoms of complications should the nurse monitor the client? Select all that apply

Anemia Dyspnea Anasarca

A client with end-stage renal disease is hospitalized. For what signs and symptoms of complications should the nurse monitor the client? Select all that apply.

Anemia Dyspnea Anasarca

To prevent bleeding after a suprapubic prostatectomy, the client should be instructed to avoid straining on defecation. Which foods should the nurse encourage the client to eat to help prevent constipation during the recovery period? Select all that apply.

Apple Oatmeal Green peas

A nurse is teaching a client who had a myocardial infarction about the prescribed 1500-calorie, 2-gram sodium, weight-reducing diet. Which low-sodium, low-calorie nutrients should the nurse recommend that the client include in the diet? Select all that apply.

Baked chicken Mashed potatoes

A nurse in a campus health clinic is assessing female students for risk factors associated with the future development of osteoporosis. What factors are included in this assessment? Select all that apply:

Cigarette smoking/ Familial predisposition/Inadequate intake of dietary calcium.

After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations should the nurse expect if the client is experiencing acute respiratory distress? Select all that apply.

Confusion Tachycardia

A 1-year-old child is found to have nutritional iron-deficiency anemia. What nursing interventions are most important in the care of an infant with iron-deficiency anemia? Select all that apply.

Conserving the infant's energy Protecting the infant from infection Teaching the parents about nutrition

A nurse is assessing a client with the diagnosis of hemorrhoids. Which factors in the client's history probably played a role in the development of the client's hemorrhoids? Select all that apply.

Constipation Numerous pregnancies

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

Cool skin Constipation Periorbital edema Decreased appetite

A client is awaiting surgery for a ruptured lumbar nucleus pulposus. Which activities should the nurse inform the client will most likely increase pain? Select all that apply.

Coughing excessively Bearing down when having a bowel movement

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

Double vision Difficulty swallowing saliva Drooping of the upper eye lids

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

Double vision Scanning speech

A toddler is admitted to the pediatric unit with a temperature of 103.5° F (40.0° C), a runny nose, and a productive cough. Respiratory secretion specimens are sent for culture and sensitivity tests. Standard precautions are followed until the results are known. What other precautions should the nurse include? Select all that apply.

Droplet Contact Airborne

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select all that apply.

Dry cerumen Difficulty hearing high-pitched voices

To help prevent long-term complications associated with gastric bypass surgery, the nurse needs to educate the client. Identify the factors that should be included in the nurse's teaching plan for this client. Select all that apply.

Eat foods rich in calcium. Consume a diet high in protein. Receive vitamin B12 injections routinely.

A nurse is caring for a client with cholelithiasis and obstructive jaundice. When assessing this client, the nurse should be alert for which common clinical indicators associated with these conditions? Select all that apply.

Ecchymosis Yellow sclera Pain in right upper quadrant

The nurse provides a dietary list to a client who is taking oral anticoagulants with foods that should be avoided because they are high in vitamin K. What foods should be included on the list? Select all that apply.

Eggs Liver Cheese

The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis? Select all that apply.

Excessive thirst Fruity-scented breath Confusion

Which clinical indicators does the nurse expect to identify when assessing a client with tic douloureux? Select all that apply.

Excruciating facial pain Twitching of the mouth

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

Fatigue Dry skin

A client who had surgery for a ruptured appendix develops peritonitis. What clinical findings related to peritonitis should the nurse expect the client to exhibit? Select all that apply.

Fever Abdominal muscle rigidity

During a client's routine physical examination, a chest x-ray film reveals a lesion in the right upper lobe. What information in the client's history supports the health care provider's diagnosis of pulmonary tuberculosis? Select all that apply.

Fever Night sweats Blood-tinged sputum

A primigravida at 38 weeks of gestation presents to the clinic with a blood pressure of 142/94, edema in all extremities, and a weight gain of five pounds since the previous checkup one week ago. During the assessment, symptoms suggestive of preeclampsia were obtained. Select all that apply.

Headache Double vision Brisk reflexes Epigastric pain

A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply.

Headache Irritability Restlessness

A nurse is planning a prenatal class about the changes that occur during pregnancy and the necessity of routine health care throughout pregnancy. Which cardiovascular compensatory mechanisms should the nurse explain will occur? Select all that apply.

Increased blood volume Increased cardiac output Enlargement of the heart

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

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

On her first visit to the prenatal clinic a client with rheumatic heart disease asks the nurse whether she has special nutritional needs. What supplements in addition to the regular pregnancy diet and prenatal vitamin and minerals will she need? Select all that apply.

Iron Folic acid

When reviewing the results of a toddler's complete blood count, a nurse concludes on the basis of decreased hemoglobin and hematocrit levels that the child has iron-deficiency anemia. Which other laboratory findings are indicative of iron-deficiency anemia? Select all that apply.

Microcytic red blood cells Slightly reduced reticulocyte count

A nurse teaches a pregnant woman about the need to increase her intake of complete proteins. Which foods identified by the client indicate that the teaching is effective? Select all that apply

Milk/Eggs/Cheese.

A client at 39 weeks' gestation is admitted for induction of labor. Knowing that several medications are used to induce labor, a nurse identifies those that may be prescribed. Select all that apply.

Oxytocin (Pitocin) Misoprostol (Cytotec) Dinoprostone (Prepidil)

A client with preeclampsia is to receive a magnesium sulfate infusion, and the nurse assesses the client's status to obtain baseline information. Which assessments are necessary? Select all that apply.

Patellar reflex Output of urine Respiratory rate

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? Select all that apply.

Assessment of skin turgor Administration of antiemetic drugs Replacement of fluid and electrolytes

A client who has had an uncomplicated myocardial infarction asks the nurse about the resumption of sexual activity. Which parameters should the nurse consider to determine the safe resumption of sexual activity? Select all that apply.

At least between 4 and 6 weeks after the myocardial infarction The point at which two flights of stairs can be climbed without dyspnea

The nurse provides care to the client with syndrome of inappropriate antidiuretic hormone (SIADH) by: Select all that apply.

Providing frequent oral care Instituting fall risk precautions Monitoring for and reporting neurologic changes

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

Psychotic behaviors Jacksonian seizures Nausea and vomiting

A nurse is providing dietary counseling to a client at 14 weeks' gestation. The client is a recent immigrant from Asia, and the nurse explores the foods that the client usually eats. Which foods should the nurse counsel the client to avoid during pregnancy? Select all that apply.

Raw shellfish/Herbal supplements/Soft-scrambled eggs.

The nurse is teaching a client who has asthma about using a peak flow meter. Which statement by the client reflects a correct understanding of the use of a peak flow meter? Select all that apply.

Readings in the green zone mean that my asthma is under control." "If I get a reading in the red zone, then I need to take my reliever drug and have my wife take me to the hospital." "I should check the peak flow readings at least twice a day."

A client at the women's health clinic tells the nurse that she has endometriosis. What factors associated with endometriosis does the nurse anticipate the client will report? Select all that apply.

Rectal pressure/Abdominal pain.

A toddler has just had a cast applied for a fractured wrist. The wrist and elbow are immobilized. What information should the nurse include in the home care instructions before discharge? Select all that apply.

Report swelling of fingers. Elevate casted arm when the child is standing.

A nurse is caring for a client with a diagnosis of varicose veins. Which clinical findings can the nurse expect to identify when assessing this client? Select all that apply.

Reports of leg fatigue, Tortuous veins in the legs Pain in lower extremities when standing

A hospitalized client is receiving pyridostigmine (Mestinon) for control of myasthenia gravis. In the middle of the night, the nurse finds the client weak and barely able to move. Which additional clinical findings support the conclusion that these responses are related to pyridostigmine? Select all that apply.

Respiratory depression Decreased blood pressure High-pitched gurgling bowel sounds

The client is returned to the surgical unit from the postanesthesia care unit (PACU) after a having a splenectomy. In the immediate postoperative period, the nurse specifically should monitor for which potential complications? Select all that apply.

Shock Abdominal distention Pulmonary complications

A nurse is teaching an adult health and wellness class about bladder cancer. The nurse informs the class participants that which activities put a person at risk for bladder cancer? Select all that apply. Smoking two packs of cigarettes a day Working with dyes and ink every day

Smoking two packs of cigarettes a day Working with dyes and ink every day

A nurse discusses dietary instructions with the parents of a toddler with acute glomerulonephritis. What nutrients does the nurse list that are restricted? Select all that apply.

Sodium Potassium

A nurse is caring for a client with end-stage renal disease who has a mature arteriovenous (AV) fistula. What nursing care should be included in the client's plan of care? Select all that apply.

Auscultate for a bruit. Palpate the site to identify a thrill. Avoid drawing blood from the affected extremity.

A client is admitted with thrombocytopenia. What specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply.

Avoid intramuscular injections. Examine the skin for ecchymotic areas.

What statement is true of ventricular dysrhythmias? Select all that apply.

The QRS complex appears widened and has a bizarre shape. The polarity of the T wave is opposite that of the QRS complex. Most ventricular dysrhythmias have no apparent P wave.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply.

The RR intervals are relatively consistent. One P wave precedes each QRS complex.

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet tall and weighs 293 pounds puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply.

Weight Smoking

A client has been taking levothyroxine (Synthroid) for hypothyroidism for three weeks. The nurse suspects that a decrease in dosage is needed when the client exhibits which clinical manifestations? Select all that apply.

Tremors Heat intolerance

Typical signs of neonatal abstinence syndrome related to opioid withdrawal usually begin within 24 hours after birth. What characteristics should the nurse anticipate in the infant of a suspected or known drug abuser? Select all that apply.

Tremors Hyperactivity

The nurse supports cognitive ability in clients with Alzheimer dementia by: Select all that apply.

Using calendars, clocks, and pictures to support memory Encouraging caregivers to support protected independence Providing a limited number of choices to support decision making

A client with hypertension is to begin a 2-gram sodium diet. The nurse should teach the client to avoid which foods? Select all that apply.

Canned chili Luncheon meat

A newly arrived Russian immigrant attends the prenatal clinic for the first time. Although she states that she has had immunizations, she does not know which ones. Which immunizations should the nurse recommend? Select all that apply.

Diphtheria/ Hepatitis B.

The nurse is caring for a client who recently returned from another country who exhibits signs and symptoms suspicious of severe acute respiratory syndrome (SARS). Which clinical manifestations support this diagnosis? Select all that apply.

Dry cough Shortness of breath Fever greater than 100.4° F

A female client whose ECG exhibits multiple premature ventricular complexes is to take oral disopyramide (Norpace). Which side effects should the nurse include when teaching the client about this drug? Select all that apply.

Dry mouth Constipation

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

Dry skin Brittle hair

A nurse is assessing a client with diabetic ketoacidosis. Which clinical manifestations should the nurse expect? Select all that apply.

Dry skin Abdominal pain Kussmaul respirations

An 83-year-old client is diagnosed with left-sided congestive heart failure. Which assessment findings should the nurse expect to find on this client? Select all that apply.

Dyspnea Crackles Cool extremities

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

Edema Hyponatremia

A nurse is collecting information about a client who has type 1 diabetes and who is being admitted because of diabetic ketoacidotic coma. Which factors can predispose a client to this condition? Select all that apply.

Excessive emotional stress Running a fever with the flu

A nurse is assessing a client with a diagnosis of diabetes insipidus. For which signs indicative of diabetes insipidus should the nurse assess the client? Select all that apply.

Excessive thirst Dry mucous membranes Decreased urine specific gravity

A pregnant client complains of constipation. Which strategies should the nurse recommend? Select all that apply.

Exercise regularly Add a few tablespoons of wheat bran to cereal at breakfast. Plan to have a bowel movement at the same time every day.

A nurse is discussing informed consent with a client who is scheduled for a hysterectomy. What should the informed consent include? Select all that apply

Explanation of available alternative treatments/Answers to questions and concerns about the procedure/Complete description of the possible dangers and discomforts.

Valsartan (Diovan), an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? Select all that apply.

Irregular pulse rate Orthostatic hypotension

What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? Select all that apply.

Joint pain Facial rash Pericarditis

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

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

nurse is caring for an older client who had non-insulin dependent diabetes for 15 years that progressed to insulin dependent diabetes 2 years ago. What common complications of diabetes should the nurse assess for when examining this client? Select all that apply.

Leg ulcers Loss of visual acuity Prolonged capillary refill in the toes Decreased sensation in the lower extremities

A client is diagnosed with Crohn's disease, and parenteral vitamins are prescribed. The client asks why the vitamins have to be given intravenously (IV) rather than by mouth. What rationales for this route should the nurse include in a response to the question? Select all that apply.

More rapid action results. They are ineffective orally. Intestinal absorption may be inadequate.

A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? Select all that apply.

My ears are ringing." It gets better when I lie down." Bright lights really bother my eyes." My head hurts more when I'm sitting watching TV."

Carbidopa/levodopa (Sinemet) is prescribed for a client with Parkinson disease. Which side effects does the nurse expect? Select all that apply.

Nausea Anorexia Mental changes

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

Nausea Dizziness Jerky lateral eye movements

A health care provider prescribes acetylsalicylic acid (aspirin) therapy for a client with arthritis, and the nurse provides teaching about the undesirable side effects of this medication. What responses should the client identify as reasons to notify the health care provider? Select all that apply.

Nausea Easy bruising Ringing in the ears

A client has been diagnosed with hyperthyroidism. The nurse expects the client to exhibit which clinical manifestations? Select all that apply.

Nervousness Increased appetite

A nurse is planning a childbirth education class about maternal psychological and physiological changes as pregnancy nears term. Which problems and concerns should the nurse include in the presentation? Select all that apply.

Nesting needs increase/Anxiety about childbirth increases/Gastrointestinal motility decreases.

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

Numbness Prolonged capillary refill

A nurse is teaching a group of clients about risk factors for heart disease. Which factors increase a client's risk for a myocardial infarction (MI)? Select all that apply.

Obesity Hypertension

A nurse is assessing a 55-year-old client who is experiencing postmenopausal bleeding. The tentative diagnosis is endometrial cancer. Which findings in the client's history are risk factors associated with endometrial cancer? Select all that apply.

Obesity/Family history of endometrial cancer/Previous hormone replacement therapy.

The client has been admitted for possible acute cholecystitis with biliary colic. What clinical findings should the nurse expect when performing a health history and physical assessment? Select all that apply.

Pain triggered by a large or high-fat meal Pain in the upper right quadrant of the abdomen Positive Blumberg's sign

A client develops internal bleeding after an abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? Select all that apply.

Pallor Tachycardia

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

Pallor Tachycardia Narrow pulse pressure

The nurse accompanies a 3-year-old child to the playroom. The toddler seems afraid to select a toy or activity. What age-appropriate play materials should the nurse offer? Select all that apply.

Plastic tea set Mold and clay Play telephone

A nurse is caring for a new mother who has a chlamydial infection. For which complications should the nurse assess the client's neonate? Select all that apply.

Pneumonia Preterm birth Conjunctivitis

After assessing a client, a nurse concludes that the client may be experiencing hyperglycemia. Which clinical findings commonly associated with hyperglycemia support the nurse's conclusion? Select all that apply.

Polyuria Polydipsia Polyphagia

What dietary choices should the nurse instruct the client taking spironolactone (Aldactone) to avoid? Select all that apply.

Potatoes Cantaloupe

A nurse is performing a newborn assessment. What characteristics cause the nurse to suspect that the newborn has Down syndrome? Select all that apply.

Protruding tongue Epicanthal eye folds One transverse palmar crease

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

Resting tremors Flattened affect Slow voluntary movements

A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? Select all that apply.

Restlessness Muscular rigidity, Respiratory tract spasms Spastic voluntary muscle contractions.

A nurse is caring for a 2-year-old child with meningitis. For which clinical manifestations of increasing intracranial pressure should the nurse assess the child? Select all that apply.

Seizures Vomiting Decreased respiratory rate

A woman comes to the emergency department reporting signs and symptoms that are determined by the health care provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? Select all that apply.

Severe fatigue Sense of unease

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply.

Shortness of breath Unilateral chest pain

A nurse is caring for a client in active labor. What positions should the nurse encourage the client to assume to help promote comfort during back labor? Select all that apply.

Sitting Lateral Knee-chest

A nurse is assessing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? Select all that apply.

Sneezing Hyperactivity High-pitched cry

The nurse understands that in a second degree atrioventricular (AV) block: Select all that apply.

Some P waves are conducted to the ventricles. Treatment consists of atropine or a pacemaker.

A home care nurse is counseling a client with amyotrophic lateral sclerosis (ALS). What information should the nurse include in the discussion? Select all that apply.

Space activities throughout the day. Anticipate the use of alternate ways to communicate.

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

Stasis ulcer Brown discoloration

A client with end-stage kidney disease (ESKD) is scheduled to receive peritoneal dialysis. What should the nurse include when teaching the client about the signs and symptoms associated with complications of peritoneal dialysis? Select all that apply.

Tachycardia Cloudy outflow Abdominal pain

A nurse is caring for a client with complications associated with peritoneal dialysis. For which signs and symptoms should the nurse monitor the client? Select all that apply.

Tachycardia Cloudy outflow Abdominal pain

A client with human immunodeficiency virus (HIV)-associated Pneumocystis jiroveci pneumonia is to receive pentamidine (Pentam) intravenously (IV) once daily. What should the nurse do to ensure client safety? Select all that apply.

Tell the client to report any evidence of bleeding immediately. Assess blood glucose levels daily and several times after therapy is completed.

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

Tender area in the posterior lower leg Warmth along the course of the involved vessel

A nurse is caring for a client who had pelvic surgery. The nurse should monitor for which clinical manifestations of thrombophlebitis? Select all that apply.

Tender area on the leg Warm area over the calf

A client undergoes pituitary surgery via the transsphenoidal route. Which foods should the nurse instruct the client to avoid after surgery? Select all that apply.

Toast Celery

The laboratory blood tests of a client at 10 weeks' gestation reveal that she has anemia. The client refuses iron supplements. The nurse teaches her that the best source of iron is liver. What other foods does the nurse encourage the client to eat? Select all that apply.

Tofu Ground beef patty

Methods for temporary pacing include: Select all that apply

Transcutaneous pacing. Transvenous pacing. Epicardial pacing.

The nurse is educating a client who is being discharged after insertion of a coronary artery stent. For what signs and symptoms should the nurse instruct the client to seek immediate medical attention? Select all that apply.

Unexplainable profuse diaphoresis Indigestion not relieved by antacids Acute chest pain after rigorous exercise Nonremitting chest pain after three sublingual nitroglycerine tablets

The nurse is educating a client who is being discharged after insertion of a coronary artery stent. For what signs and symptoms should the nurse instruct the client to seek immediate medical attention? Select all that apply.

Unexplainable profuse diaphoresis Indigestion not relieved by antacids Acute chest pain after rigorous exercise Nonremitting chest pain after three sublingual nitroglycerine tablets

A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply.

Unilateral chest pain Acute onset of dyspnea

A client has a new diagnosis of hyperthyroidism. Which skin conditions should the nurse expect when performing a physical assessment? Select all that apply

Warm Moist Smooth

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

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

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

Weakness Hypertension Truncal obesity

During a home visit the nurse obtains information about a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply.

Lethargy Ambivalence Emotional lability

A client who has been taking spironolactone (Aldactone) is admitted to the hospital with hypokalemia. The nurse will assess the client for which clinical findings? Select all that apply.

Lethargy Thready, weak pulse Muscle weakness

An older client asks, "How do I know that all the medications that I take are safe?" What information should the nurse include in a response to this client's question? Select all that apply.

"Ask your health care provider how and when you should be taking your medications." "Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy." "Inform your health care provider of the over-the-counter drugs, recreational drugs, and amount of alcohol you ingest."

A client with hyperthyroidism is being treated with propylthiouracil (PTU). What instruction should the nurse plan to include in the teaching plan regarding this drug? Select all that apply.

"Avoid abrupt discontinuation of the medication." Monitor your weight, pulse, and mood routinely." "Report side effects, such as sore throat, fever, joint pain, or oral lesions."

The nurse is providing preoperative teaching for a client who is to have cataract surgery. Which is appropriate for the nurse to include concerning what the client should do after surgery? Select all that apply.

Avoid bending from the waist. Do not blow your nose.

A client with gastroesophageal reflux disease (GERD) should make diet and lifestyle changes. What instructions should the nurse include in the client's discharge teaching? Select all that apply.

Avoid caffeine-containing products. Chew thoroughly while eating slowly

A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching has been understood when the client makes what statements? Select all that apply.

"I should drink eight glasses of water every day." "I can include bran muffins in my breakfast daily." "I will walk every day as part of my exercise regimen."

Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? Select all that apply.

"I sometimes allow our children to sleep in our bed at night." "I know I also have tuberculosis because the skin test was positive." "I'll be skipping the wine but enjoying the cheese at my neighbor's party."

The nurse is providing discharge teaching to a client with acquired immunodeficiency syndrome (AIDS) whose white blood cell count (WBC) is low. Which statement indicates a need for further education? Select all that apply.

"I will eat at least one piece of fresh fruit every day." I will walk at the mall twice a week to keep up my strength."

An almost term client reports that her fetus is moving less this week than last week. Which responses are appropriate? Select all that apply.

"It would be good for you to come to labor and delivery to be evaluated today." "Always call the health care provider if you're worried that your baby isn't moving enough." "Let me teach you how to conduct a kick count, and then you can call me when you've done one."

A client comes to the ambulatory surgery unit on the morning of an elective surgical procedure. The client reports shortness of breath, dizziness, and palpitations. The nurse observes profuse diaphoresis and is concerned that the client may be having either a panic attack or a myocardial infarction. Which assessments support the conclusion that the client may be experiencing a myocardial infarction? Select all that apply.

Anxiety Chest pain Irregular pulse

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

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

A nurse is providing discharge instructions for a client with a diagnosis of gastroesophageal reflux disease (GERD). What should the nurse advise the client to do to limit symptoms of GERD? Select all that apply.

Avoid heavy lifting. Avoid drinking alcohol Eat small, frequent meals.

A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teaching? Select all that apply.

Carrots Leafy greens

The nurse teaches a client about the increased need for vitamin A to meet the demands imposed by rapid fetal tissue growth during pregnancy. Which foods should the nurse encourage the client to ingest to meet this increased need? Select all that apply.

Carrots/Sweet potatoes.

A nurse determines that a newborn is in respiratory distress. Which signs confirm this assessment? Select all that apply.

Cyanosis Tachypnea Retractions

A client with mild preeclampsia is admitted to the high-risk prenatal unit because her blood pressure is progressively increasing. The nurse reviews the practitioner's prescriptions. What prescriptions does the nurse expect? Select all that apply.

Daily weight Side-lying bed rest Deep tendon reflexes

A toddler is admitted to the pediatric unit with diarrhea and severe dehydration. After several days of treatment the child is evaluated. What clinical findings indicate that the child is rehydrated? Select all that apply.

Decreased hematocrit Increase in daily weight Decreased blood urea nitrogen level

A client has a hysterectomy, salpingoophorectomy, tumor removal, and multiple abdominal biopsies for ovarian cancer. For which clinical manifestations should the nurse assess the client that indicates that the client may be experiencing a pulmonary embolus? Select all that apply.

Decreased oxygen saturation level Sudden onset of shortness of breath

The adverse hemodynamic effects of a fast heart rate may be caused by: Select all that apply

Decreased ventricular filling time. Less cardiac output.

A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition? Select all that apply

Deep bone pain Depressed deep tendon reflexes

A client is diagnosed as having colitis. Which clinical findings should the nurse expect the client to report? Select all that apply.

Diarrhea Abdominal cramps

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply.

Fever Tachypnea Abdominal rigidity

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply.

Flaccid paralysis Lack of reflexes below the injury

A client expresses concern about insomnia and asks, "What can I do to get better sleep?" What activities should the nurse recommend? Select all that apply.

Follow the same bedtime ritual each night Perform deep-breathing exercises

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

Hirsutism Round face Buffalo hump

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

Hyperkalemia Hyponatremia Postural hypotension

A client with a diagnosis of acquired immunodeficiency syndrome (AIDS) has a protozoal infection and is receiving pentamidine (NebuPent). The nurse should monitor the client for which common side effects? Select all that apply.

Hypoglycemia Decreased blood pressure

A nurse is administering intravenous aminophylline to a client with asthma. Which clinical findings support the conclusion that the client is experiencing an adverse reaction to aminophylline? Select all that apply.

Hypotension Cardiac dysrhythmia Muscle hyperactivity

The nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which statement by the client indicates a good understanding of preventing dumping syndrome after meals? Select all that apply.

I will not drink fluids when I eat meals." "I will eat small, frequent meals instead of three large meals a day." "I will avoid sweetened and spicy foods."

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

Increased weight Decreased serum sodium Decreased level of consciousness

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse should assess for which complications? Select all that apply.

Infection Hyperglycemia Electrolyte imbalance

The nurse observes a 2-year-old child at play and concludes that the child is engaging in age-appropriate behavior for a toddler. Which activities lead the nurse to this conclusion? Select all that apply.

Is possessive of toys Follows simple directions

After surgery a client is started on a clear liquid diet. Which should the nurse offer the client? Select all that apply.

Jell-O Broth Ginger ale

A nurse provides dietary teaching for a client with an acute exacerbation of colitis, and afterward the client makes a list of foods that can be included on the diet. Which food choices indicate that the teaching was effective? Select all that apply.

Jelly sandwich Lean roast beef Scrambled eggs

A nurse teaches a client with gastrointestinal (GI) irritability to minimize the intake of dietary irritants. Which products did the nurse teach the client to avoid? Select all that apply.

Milk Cheese Chocolate candy

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply.

Milk and eggs, Whole grains, Cooked fruit and vegetables

A client is diagnosed with malabsorption syndrome. Which foods should the nurse teach the client to avoid? Select all that apply.

Oatmeal Rye bread

A client is admitted to the hospital for surgery for rectosigmoid colon cancer, and the nurse is obtaining a health history as part of the admission process. What clinical findings associated with rectosigmoid colon cancer does the nurse expect the client to report? Select all that apply.

Rectal bleeding Change in the shape of stools Feeling of abdominal bloating

A woman visits the prenatal clinic because an over-the-counter pregnancy test has rendered a positive result. After the initial examination verifies the pregnancy, the nurse explains some of the metabolic changes that occur during the first trimester of pregnancy. Select all that apply.

Sleep needs increase/ Fluid retention increases/ Calcium requirements increase.

What are the indicators of nutritional risk in pregnancy in a client who is of normal weight? Select all that apply.

Smoker Twin gestation

A nurse in the pediatric clinic is advising the mother of a toddler who has a pinworm infestation. What should the nurse teach the mother about caring for her child during and after treatment? Select all that apply.

Strategies to prevent reinfestation The need for medication for the entire family The importance of handwashing before eating

Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply.

Tachycardia Exophthalmos

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

Weight gain Cold intolerance

A client is taking an antithyroid medication for hyperthyroidism. The nurse provides education about serious health problems that may develop if the medication is not effective and tachycardia continues. The nurse instructs the client to seek medical attention immediately if any of the problems occur. Which should be included in the teaching? Select all that apply.

Weight gain Pedal edema

A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for which responses? Select all that apply.

Weight loss Excessive loss of potassium ions

Which of the following symptoms indicates to the nurse that the client has an inadequate fluid volume? Select all that apply.

Decreased urine Hypotension Dry mucous membranes Poor skin turgor

What findings occur with supine hypotensive syndrome? Select all that apply.

Feeling of faintness Increased venous pressure Decreased systolic pressure

A nurse is caring for a pregnant client with thrombophlebitis. Which anticoagulant medication may be prescribed? Select all that apply.

Heparin (Hep-Lock) Enoxaparin (Lovenox)

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

Iced tea, Hot cocoa Chocolate pudding

A nurse is planning education for a parent group related to procedures to be taken if accidental poisoning is suspected. What should the nurse include? Select all that apply.

Identify the material ingested Call the poison control center

What are expected changes that the nurse might identify when assessing the skin of an older adult? Select all that apply.

Increased wrinkles Hyperpigmented patches

While reviewing the health history of a newborn with suspected jaundice, the nurse recalls that some risk factors place infants at a higher risk developing jaundice. Which conditions are risk factors for jaundice? Select all that apply.

Infection Prematurity Breastfeeding Maternal diabetes

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected, and a test for the human immunodeficiency virus (HIV) is performed. Which clinical responses are associated most commonly with this syndrome? Select all that apply.

Malaise Swollen lymph glands

The nurse is caring for a client who is scheduled to have a percutaneous liver biopsy. Which assessment findings warrant the postponement of the procedure? Select all that apply.

Marked ascites Hemoglobin of less than 9 g/dL

The pathology report states that a client's urinary calculus is composed of uric acid. The nurse should instruct the client to avoid which food items. Select all that apply

Meat extracts Organ meats

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which classic signs of hepatic coma should the nurse assess this client? Select all that apply.

Mental confusion Flapping hand tremors

An older African-American client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? Select all that apply.

Occasional cocaine use African-American heritage

A client is diagnosed with gastric cancer, and a subtotal gastrectomy is performed. After surgery the client begins to hemorrhage. What clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply.

Oliguria Diaphoresis Tachycardia

While recovering from abdominal surgery a client develops thrombophlebitis. Which clinical indicators of this complication should the nurse expect to identify when assessing the client? Select all that apply.

Pain in the calf Redness in the affected area Localized warmth in the lower extremity

What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? Select all that apply.

Pain management with oral analgesics Assessment of the site every 15 minutes Application of an ice pack for 20-minute intervals

A nurse is testing a newborn's heel blood for the level of glucose. Which newborn does the nurse anticipate will experience hypoglycemia? Select all that apply.

Preterm infant Small-for-gestational-age infant Large-for-gestational-age infant

A nurse is caring for a client with a Venturi mask who is receiving 40% oxygen. What nursing actions are indicated? Select all that apply.

Prevent the client's blanket from covering the adaptor's orifices. Check that the appropriate adaptor to deliver the prescribed FiO2 is attached to the mask.

A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. For which risk factors should the nurse assess the client that most likely may have caused the hyponatremia? Select all that apply.

Profuse diaphoresis Rapid IV infusion of 5% dextrose in water

After an assessment of a male newborn, the nurse suspects postmaturity. Which observations help confirm this conclusion? Select all that apply.

Profuse scalp hair Parchmentlike skin Creases covering the entire soles

A nurse advises a client receiving furosemide (Lasix) to increase potassium intake. Which fruit should the nurse encourage the client to eat? Select all that apply.

Prune Banana

A client who is HIV positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through: (Select all that apply.)

semen. Blood

A woman has made the decision to have breast augmentation surgery, and the procedure is to be performed on an outpatient basis. As part of the preoperative protocol, the nurse provides teaching regarding the discharge instructions. Which instructions apply to this type of surgery? Select all that apply.

"Avoid taking aspirin or NSAIDs (e.g., ibuprofen [Advil]) for pain relief/ Sleep with your head and torso elevated for at least 1 week/ Take your temperature daily and notify the clinic if it goes above 99.6° F .

A client with a history of three spontaneous abortions is now at 16 weeks' gestation and attending the high-risk prenatal clinic. She expresses concerns about remaining at home during this pregnancy. Which questions will elicit responses most helpful to the nurse developing the client's plan of care? Select all that apply.

"Do you have a support system available to help you?" Have you been told about the status of your pregnancy?"

Which nursing activities are examples of primary prevention? Select all that apply.

Assisting with immunization programs Facilitating a program about smoking cessation

Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply.

Encouraging regular dental checkups Teaching the procedure for breast self-examination

A nurse is assessing a client with the diagnosis of scleroderma for signs of calcium deposits in organs, Raynaud phenomenon, esophageal dysfunction, sclerodactyly (scleroderma of the digits), and telangiectasia (vascular lesions formed by dilation of a group of small blood vessels [CREST syndrome]). What clinical indicators should the nurse expect to identify? Select all that apply.

Esophageal reflux Spider-like hemangiomas Episodic blanching of the fingers

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

Hyperkalemia Hyponatremia Postural hypotension

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

Hyperthermia Splenomegaly

A nurse assessing a newborn suspects Down syndrome. Which characteristics support this conclusion? Select all that apply.

Hypotonia Singe transverse palmar crease Epicanthal eye folds

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

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

Which statements by a client with hyperemesis gravidarum would confirm that the client needs further teaching? Select all that apply:

I'll start limiting my carbohydrates/I'll lie down for at least 2 hours after I eat.

A nurse is preparing to administer the prescribed digoxin (Lanoxin) intravenously (IV) to a client. Which nursing interventions are associated with IV digoxin administration? Select all that apply.

Monitor the heart rate closely Check the blood levels of digoxin Monitor the serum potassium level

A client is admitted to the hospital with a diagnosis of chronic kidney disease. Which responses should the nurse expect the client to exhibit? Select all that apply.

Paresthesias Hypertension

When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions. Select all that apply.

Breathing Pulse rate Blood vessel diameter

A client has a low hemoglobin level that is attributed to a nutritional deficiency. Which foods should the nurse teach the client to increase in the diet? Select all that apply.

Liver Raisins Spinach

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

Liver Shellfish

The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? Select all that apply.

Low sodium diet Daily abdominal girth measurements Daily weights

A client is recovering from an acute episode of alcoholism that included esophageal involvement. What are the components of a therapeutic diet that are most appropriate for the nurse to include in the teaching plan for this client? Select all that apply.

Soft diet High-protein diet High-carbohydrate diet

A female client has a low hemoglobin level, which is attributed to an iron deficiency. Which foods should the nurse recommend that the client increase in the diet? Select all that apply.

Spinach Beef liver Baked beans

The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in vitamin K and that should be avoided. What should the nurse include on the list? Select all that apply.

Spinach Broccoli

A pregnant client is concerned that she may have been infected with HIV. What information should a nurse include when counseling this client about HIV testing? Select all that apply.

The risks of passing the virus to the fetus What positive or negative test results indicate The emotional, legal, and medical implications of test results

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

Tinnitus Weakness Leg cramps

A nurse is assessing several postpartum clients. Which conditions increase the risk for postpartum hemorrhage? Select all that apply.

Twin birth Overdistended bladder Retained placental fragments

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

Epistaxis Hematuria Hemarthrosis Easy bruising Dark colored tarry stool

What nursing actions best promote communication when obtaining a nursing history? Select all that apply.

Establishing eye contact Paraphrasing the client's message Using broad, open-ended statements

A pregnant client with sickle cell anemia visits the clinic each month for a routine examination. What additional assessment should be made during every visit? Select all that apply.

Evidence of urinary tract infection Presence of hyperemesis gravidarum

A nurse is performing a physical assessment of a client with gout. What parts of the client's body should the nurse assess for the presence of tophi (urate deposits)? Select all that apply.

Feet Ears

Neonates have difficulty maintaining their body temperature, but their bodies have several mechanisms to help them do so. Which ones should a nurse remember when caring for a newborn? Select all that apply.

Flexed fetal position Brown fat metabolism Peripheral vasoconstriction

A client recovering from a gastric resection for gastric cancer is started on small frequent meals. The nurse evaluates the client's response 30 minutes after nutritional intake and determines that the client is experiencing dumping syndrome if which of the following signs and symptoms are observed? Select all that apply.

Flushing Diarrhea Sweating

An active adolescent is admitted to the hospital for surgery for an ileostomy. When planning a teaching session about self-care, the nurse includes sports that should be avoided by a client with an ileostomy. Which should be included on the list of sports to be avoided? Select all that apply.

Football Ice hockey

The nurse teaches the client about foods to help prevent constipation after pelvic surgery. Which foods selected by the client indicate that the teaching is understood? Select all that apply.

Green vegetables Whole grain bread

The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? Select all that apply.

Hemoptysis Night sweats

Which interventions should the nurse anticipate will be prescribed initially for a client who had a hemorrhoidectomy? Select all that apply.

Applying moist heat Administering stool softeners

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

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

A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis. Which clinical findings related to this event should the nurse document in the client's clinical record? Select all that apply.

Acetone breath Decreased arterial carbon dioxide level

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

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

A client is admitted with a tentative diagnosis of pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolyte balance, and decreasing anxiety. Which interventions should the nurse implement? Select all that apply.

Administer analgesics. Teach relaxation exercises. Monitor cardiac rate and rhythm.

A client who is lying in the supine position while in active labor is receiving an intravenous oxytocin (Pitocin) infusion and has external monitors in place. Using the monitoring strips below, identify the appropriate nursing interventions. Select all that apply.

Administer oxygen. Turn the client on the side. Discontinue the oxytocin infusion.

A client in her 10th week of pregnancy exhibits presumptive signs of pregnancy that the nurse may detect, including which of the following? Select all that apply.

Amenorrhea Breast changes Urinary frequency

The nurse is caring for the unconscious neurological client. In her assessment she notes increased restlessness. What could the client be exhibiting? Select all that apply.

Anoxia A return to consciousness Distended bladder

A client with achalasia is to undergo bougienage to dilate the lower esophagus and cardiac sphincter. For which clinical manifestations should the nurse assess the client after the procedure? Select all that apply.

Abdominal pain Increased heart rate Increased blood pressure

Four days after a vaginal hysterectomy a client calls the follow-up service and tells the nurse that she has a yellowish-green vaginal discharge. The nurse advises the client to return to the clinic for an evaluation. What does the nurse need to assess when a vaginal infection is suspected? Select all that apply:

Abdominal pain/Rising temperature.

A nurse is caring for a client with acute renal failure. Which findings should the nurse anticipate when reviewing the laboratory report of the client's blood level of calcium, potassium, and creatinine? Select all that apply.

Calcium: 7.6 mg/dL Potassium 6.0 mEq/L Creatinine: 3.2 mg/dL

A nurse is caring for a client with end-stage renal disease. Which clinical indicators of end-stage renal disease should the nurse expect? Select all that apply.

Azotemia Hypertension

A nurse teaches a client with calcium-based renal calculi about foods that can be eaten on a low-calcium diet (400 mg/day). The nurse concludes that the teaching was effective when the client selects what food items from the menu? Select all that apply.

Baked chicken Roast beef with mashed potato

Ibuprofen (Motrin) and hydroxychloroquine (Plaquenil) are prescribed for an older client with arthritis. The nurse teaches the client about these medications. What responses to the medication should the client be taught to report? Select all that apply.

Blurred vision Bleeding tendencies

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

C AND D

The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply

Capillary refill, Pulse skin temperature Movement and sensation

The nurse is instructing the student nurse how to administer percutaneous enterostomal gastrostomy (PEG) tube feeding to a client. What should the nurse tell the student? Please select all that apply.

Check prescription for correct client formula. Connect tube feeding bag to client and feeding pump. Check for residual before beginning feeding. Flush with warm water before beginning feeding. Set correct rate and initiate pump

After a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension, a client is discharged on a regimen that includes chlorothiazide (Diuril). What should the nurse instruct the client to do regarding nutrition? Select all that apply.

Eat more citrus fruits Increase intake of dried cooked beans

A nurse is performing the physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. The nurse expects to observe what skin conditions? Select all that apply.

Ecchymoses Telangiectasis

A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? (Select all that apply.)

Gloves Gown Goggles

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

Gloves Hand hygiene

Which intervention may be delegated to nursing assistive personnel (NAP)? Select all that apply.

Having a client care technician obtain routine vital signs Having a client care technician ambulate a stable client

A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 and she has 2+ protein in her urine and edema of the hands and face. For which signs or symptoms should the nurse assess the client to determine whether HELLP syndrome is developing? Select all that apply.

Headache Abdominal pain Flulike symptoms

When entering a room on a medical unit, the nurse identifies that a client is having a seizure. What should the nurse do in addition to protecting the client from self-injury? Select all that apply.

Monitor the seizure activity. Turn the client on the left side.

A client is diagnosed with calcium oxalate renal calculi. Which foods should the nurse teach the client to avoid? Select all that apply.

Nuts Spina Rhubarb

A nurse is assessing a newborn with trisomy 21 (Down syndrome). What clinical findings does the nurse expect? Select all that apply.

Protruding tongue Hypotonic muscle tone Broad nose with a depressed bridge

What are the best ways for a nurse to be protected legally? Select all that apply.

Provide care within the parameters of the state's nurse practice act. Document consistently and objectively. Clearly document a client's non-adherence to the medical regimen.

The nurse provides care to the client with diabetes insipidus (DI) following head injury by: Select all that apply.

Providing adequate fluids within easy reach Assessing for and reporting changes in neurological status Monitoring for constipation, weight loss, hypotension, and tachycardia

A nurse is assessing a newborn with a myelomeningocele. What clinical findings prompt the nurse to suspect hydrocephalus? Select all that apply.

Tense fontanels High-pitched crying A defect in the lumbosacral area

A nurse caring for a pregnant client and her partner suspects domestic violence. Which assessments support this suspicion? Select all that apply.

The woman has injuries to the breasts and abdomen/The partner answers questions that are asked of the woman/The woman has visited the clinic several times in the last month.

Evidence-based nursing uses a variety of sources to support nursing practice. Which are sources of evidence-based practice? Select all that apply.

Theory Research Clinical expertise

A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply.

Thin upper lip Small upturned nose Smooth vertical ridge in the upper lip

The nurse is caring for a client who is postoperative day 2 open of a cholecystectomy and notes the presence of bibasilar crackles. The nurse suspects atelectasis. Which nursing actions would be appropriate for this client? Select all that apply.

Perform frequent breath sounds assessment. Encourage turning, coughing, and deep breathing exercises.

A health care provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply.

Obtaining the client's vital signs Determining typing and crossmatching of blood Using a Y-type infusion set to initiate 0.9% normal saline

A nurse identifies that a client may be dehydrated. Which clinical manifestations would the client exhibit? Select all that apply.

Oliguria Hypotension Tenting tissue turgor

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

Oliguria Seizures Vomiting

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

Tachypnea Increased pulse rate

A client's laboratory report indicates the presence of hypokalemia. For which clinical manifestations associated with hypokalemia should the nurse assess the client? Select all that apply.

Anorexia Leg cramps

A client with chronic heart failure is taking a diuretic twice a day. The health care provider prescribes a diet that includes the intake of dietary potassium. What foods that have a higher amount of potassium should the nurse instruct the client to consume? Select all that apply.

Bananas Baked potatoes with skins

The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply.

Capillary refill, temperature, puls

When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply.

Dependent rubor Ulcers on the toes Delayed capillary refill

A client's nipples become sore and tender as a result of her newborn's vigorous suckling. What should the nurse recommend that the mother do to alleviate the soreness? Select all that apply.

Expose the nipples to air several times a day/ Apply hydrogel pads to the nipples after each feeding.

During a routine examination, an enlarged thyroid gland is discovered in a client, and hyperthyroidism is suspected. What clinical findings should the nurse expect to identify when completing a nursing admission history and physical for this client? Select all that apply.

Palpitations Tachycardia Menstrual disturbances

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

Thirst Fruity breath odor Excessive urination

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply.

Unusual fatigue Dependent edema Nocturnal dyspnea

The nurse is planning to teach a client with heart failure about the signs and symptoms of cardiac decompensation. What clinical manifestations should the nurse include? Select all that apply.

Extreme fatigue Coughing at night Difficulty breathing

A nurse assesses a newly admitted client with a diagnosis of pulmonary tuberculosis (TB). Which clinical findings support this diagnosis? Select all that apply.

Fatigue Hemoptysis Night sweats

Which healthy snacks should the nurse teach the parents to give their 2-year-old child who has a diagnosis of acute asthma? Select all that apply.

Apple slices Sliced vegetables

A client who has just begun breastfeeding complains that her nipples feel very sore. What should the nurse encourage the mother to do? Select all that apply.

Apply cool packs to her breasts to reduce the discomfort/Take the analgesic medication prescribed to limit the discomfort/Assume a different position when breastfeeding to adjust the infant's sucking.

A nurse is taking care of a client with cirrhosis of the liver. For which clinical manifestations should the nurse assess? Select all that apply.

Ascites Pruritus Jaundice

A child in sickle cell crisis is admitted to the pediatric unit. Supportive care includes: Select all that apply.

Bedrest, Oxygen via nasal cannula Acetaminophen (Tylenol) Age appropriate activities Intravenous hydration

A pregnant woman tells a nurse in the prenatal clinic that she knows that folic acid is very important during pregnancy and that she is taking a prescribed supplement. She asks the nurse what foods contain folic acid (folate) so she may add them to her diet in its natural form. Which foods should the nurse recommend? Select all that apply.

Black and pinto beans Enriched bread and pasta

A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply.

Butterfly facial rash Inflammation of the joints

A client had a laproscopic cholecystectomy. Postoperatively the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What should the nurse include in the teaching plan when preparing this client for discharge? Select all that apply.

Call the health care provider if you have a fever of 100o F or more for two days. Check the puncture sites daily for redness, tenderness, swelling, heat, or drainage.

The nurse is monitoring a client who is having a third transfusion of packed red blood cells. Which of these may be evident if the client is experiencing a febrile transfusion reaction? Select all that apply.

Chills, Hypotension Tachycardia

An ambulatory female client with relapsing-remitting multiple sclerosis is to receive every-other-day injections of interferon beta-1a (Avonex). What adverse effects should the nurse explain may occur when taking this medication? Select all that apply.

Depression Constipation Flulike symptoms Increased heart rate

A client asks the nurse about the use of an intrauterine device (IUD) for contraception. What information should the nurse include in the response? Select all that apply.

Expulsion of the device/ Occasional dyspareunia/ Risk for perforation of the uterus.

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

Fatigue Dry skin

A nurse is assessing a client with a brain tumor. Which clinical findings indicate an increase in intracranial pressure? Select all that apply.

Fever Stupor

A client at 7 weeks' gestation tells the nurse in the prenatal clinic that she has been bothered by episodes of nausea, but no vomiting, throughout the day. What should the nurse recommend? Select all that apply.

Focus on and repeat a rhythmic chant/Eat small, frequent meals and eat dry crackers in between.

A nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? Select all that apply.

Foramen ovale Ductus arteriosus

Which clinical indicators does the nurse identify that suggest that a client is experiencing urinary retention and overflow after a cerebrovascular accident (also known as a "brain attack")? Select all that apply.

Frequent voidings Suprapubic distention

A client with a history of heart failure admits to the nurse that a salt-restricted diet has not been followed. The client reports increased ankle swelling and shortness of breath that is relieved by sitting up. For what other clinical indicators of fluid retention should the nurse monitor the client? Select all that apply.

Headache Crackles on lung auscultation

A nurse is assessing a client for dehydration, The client has had diarrhea and vomiting for 48 hours. What are indicators of dehydration? Select all that apply.

Headache The skin on the client's forehead remains tented after being pinched

A nurse, caring for a client with uncontrolled diabetes, suspects that a client is experiencing hypoglycemia in response to insulin administration. What clinical manifestations lead the nurse to this conclusion? Select all that apply.

Headache Confusion Profuse sweating

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

Nystagmus Scanning speech Intention tremors

A client is diagnosed with sprue (adult celiac disease). What should the nurse teach the client to avoid when providing dietary teaching? Select all that apply.

Oatmeal Spaghetti

A nurse is caring for an adolescent in labor an hour after she was admitted to the birthing unit. The adolescent is anxious and tense. She cries during contractions and asks the nurse for epidural anesthesia. The nurse obtains the adolescent's current vital signs and reviews her history and admission information. What nursing interventions are essential before epidural anesthesia is administered? Select all that apply.

Performing a baseline vaginal examination/Telling the adolescent what to expect with each procedure/Identifying risk factors that contraindicate epidural anesthesia.

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply.

Prayer Hypnosis Aromatherapy Guided imagery

A client who has been receiving hemodialysis for several years is to receive a kidney transplant. What should the nurse say in the client's preoperative teaching plan? Select all that apply.

Precautions are needed to prevent infection The kidney may not function immediately A urinary catheter will be present postoperatively

A nurse is teaching a client about prophylactic measures that minimize the risk of contracting hepatitis B. Which actions should be included in this teaching plan? Select all that apply.

Screening of blood donors Maintaining a monogamous sexual relationship

A woman who is 34 weeks pregnant is hospitalized for pyelonephritis. What assessments should the nurse include in the plan of care? Select all that apply.

Urine output Temperature Blood pressure Uterine contractions

A client who is taking an oral contraceptive calls the nurse with concerns about side effects of the medication. Which adverse effect of this medication should alert the nurse to inform the client to immediately stop the contraceptive and contact the health care provider? Select all that apply.

Visual disturbances Persistent headaches

Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease. The nurse monitors the client for which side effects of the medication? Select all that apply.

Vomiting Anorexia Changes in mood

A client reports pain as a result of a gastric ulcer. What clinical findings is the nurse most likely to identify during an assessment of the client's pain? Select all that apply.

Vomiting relieves pain. Pain described as gnawing. Pain occurs a half hour after meals

A client with the diagnosis of chronic kidney disease develops hypocalcemia. Which clinical manifestations should the nurse expect the client with hypocalcemia to exhibit? Select all that apply.

Chvostek sign Muscle cramps

A client is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis? Select all that apply.

Headache Abdominal pain Visual disturbances

A nurse is caring for a client who is receiving internal radiation for cancer of the cervix. For which adverse reactions to the radiotherapy should the client be monitored? Select all that apply

Hemorrhage/Increased temperature.

A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply.

Hips Knees

The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply.

Rapid pulse, Decreased urinary output

A client with ascites has a paracentesis, and 1500 mL of fluid is removed. The nurse recognizes that it is important to monitor the client for what signs of complications that may occur immediately after the procedure? Select all that apply.

Rapid thready pulse Decreased blood pressure

A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply.

Rapid, thready pulse Elevated specific gravity

A client's laboratory values demonstrate an increased serum calcium level, and further diagnostic tests reveal hyperparathyroidism. For what clinical manifestations should the nurse assess this client? Select all that apply.

Cardiac dysrhythmias Hypoactive bowel sounds

A nurse is teaching a prenatal class about the changes that occur during the second trimester of pregnancy. What cardiovascular changes should the nurse include? Select all that apply.

Cardiac output increases/Blood pressure decreases/The heart is displaced upward.

An older client asks, "How do I know that all the medications that I take are safe?" What information should the nurse include in a response to this client's question? Select all that apply.

Ask your health care provider how and when you should be taking your medications." Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy." "Inform your health care provider of the over-the-counter drugs, recreational drugs, and amount of alcohol you ingest."

The nurse provides postoperative care to the client following subtotal thyroidectomy by: Select all that apply.

Assessing for frequent swallowing Ambulating the client the evening of surgery Assessing for facial spasms, apprehension, or tingling of the lips, fingers, or toes Ensuring that oxygen, suction equipment, and a tracheosomy tray are at the bedside

The nurse prepares a list of recommended foods for a client with hypertension that is to begin a 2-gram sodium diet. The list should include which foods? Select all that apply.

Beef steaks Cooked broccoli

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

Contact precautions Airborne precautions

The nurse plans interventions for a client with smoke inhalation based on a negative chest x-ray and arterial blood gases that show a Po2 of 85 mm Hg, a PCO2 of 45 mm Hg, and a pH of 7.35. Which interventions should the nurse anticipate will be prescribed? Select all that apply.

Coughing Deep breathing Humidified oxygen

A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? Select all that apply.

Cracked and peeling skin Long scalp hair and fingernails Creases covering the neonate's full soles and palms

For which side effects should a nurse assess a client with cancer who is being treated with chemotherapeutic agents? Select all that apply.

Diarrhea Bleeding tendencies

A newly arrived Russian immigrant attends the prenatal clinic for the first time. Although she states that she has had immunizations, she does not know which ones. Which immunizations should the nurse recommend? Select all that apply.

Diphtheria Hepatitis B

A client undergoes anterior and posterior surgical repair of a cystocele and rectocele and returns from the postanesthesia care unit with an indwelling catheter in place. What should the nurse tell the client about the primary reasons for the catheter? Select all that apply.

Discomfort is minimized/Retention of urine is prevented/ Pressure on the suture line is relieved.

A client with left ventricular heart failure is taking digoxin (Lanoxin) 0.25 mg daily. What changes does the nurse expect to find if this medication is therapeutically effective? Select all that apply.

Diuresis Decreased edema Decreased pulse rate

A paracentesis is prescribed for a client recently admitted to a medical unit. The nurse recalls that the procedure is performed for what reasons? Select all that apply.

Extract peritoneal fluid Improve respiratory status Obtain peritoneal fluid for culture

A nurse is obtaining a history and performing a physical assessment of a client who has cancer of the tongue. Which clinical findings should the nurse expect to identify? Select all that apply.

Leukoplakia Alterations in taste Enlarged cervical lymph nodes

At 42 weeks' gestation a client gives birth to an 8-lb 5-oz newborn. On examining the infant, what does the nurse expect to observe? Select all that apply.

Long nails Wrinkled skin

A nurse obtains a health history from the parents of a toddler who is admitted to the pediatric unit with the diagnosis of acute lymphocytic leukemia (ALL). What problems does the nurse expect the parents to report? Select all that apply.

Loss of appetite Paleness of the skin Purplish spots on the skin

The nurse, teaching a client in early pregnancy about the need to increase her intake of complete proteins, asks the client to identify foods that contain these proteins. Which response indicates that client understands the teaching? Select all that apply.

Milk, eggs, and cheese/Fish, hamburger, and chicken.

The client is admitted to the hospital with a large goiter, and a thyroidectomy is performed. What should the nurse do during the first four hours after the surgery? Select all that apply

Monitor for stridor or dyspnea . Assess the sides and back of the client's neck for evidence of bleeding.

Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply.

Monitoring deep tendon reflexes Maintaining a dark, quiet environment Using a pump to regulate the medication Having calcium gluconate available at the bedside

A client was admitted to the hospital with blunt trauma as a result of a collision with the steering wheel during a motor vehicle accident. The client was treated for a lacerated liver and abdominal hemorrhage. Which clinical findings should the nurse be alert for when assessing the client for peritonitis during the recovery period? Select all that apply.

Muscle rigidity Abdominal tenderness Decreased bowel sounds

An emergency tracheotomy is performed on a toddler in acute respiratory distress from laryngotracheobronchitis (viral croup). What early signs of respiratory distress indicate that it is necessary for the nurse to suction the tracheotomy? Select all that apply.

Restlessness Increased pulse rate

What are the primary nursing interventions when a client is receiving an infusion of magnesium sulfate for severe preeclampsia? Select all that apply.

Restricting visitors Maintaining a quiet environment

Laboratory results of a client's blood after chemotherapy indicate bone marrow depression. What should the nurse encourage the client to do? Select all that apply.

Use a soft toothbrush., Read the ingredients in over-the-counter drugs before taking them

A client is diagnosed with hyperthyroidism and is experiencing exophthalmia. Which measures should the nurse include when teaching this client how to manage the discomfort associated with exophthalmia? Select all that apply.

Use tinted glasses. Elevate the head of the bed 45 degrees. Tape eyelids shut at night if they do not close.

Women who become pregnant for the first time at a later reproductive age (35 years or older) are at risk for what complications? Select all that apply.

Preterm labor Multiple gestation Chromosomal anomalies Bleeding in the first trimester

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply.

Oliguria Irritability Hypotension

A client with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The nurse should monitor the client for which manifestations of complications? Select all that apply.

Tachycardia Cloudy outflow Abdominal pain

A nurse is assigned to care for an infant in the newborn nursery who was born 4 hours ago. Maternal substance abuse is strongly suspected. Which symptoms are seen in neonates demonstrating signs of drug withdrawal? Select all that apply.

Tachypnea Exaggerated Moro reflex Prolonged, high-pitched cry Restlessness and excessive activity

Which food selections by a client with malabsorption syndrome indicate that the nurse's dietary teaching was successful? Select all that apply.

Green beans Baked potato

A client with an exacerbation of colitis is placed on a low-residue, bland, high-protein diet. Vitamins B, C, and K are being administered parenterally. The client asks why this dietary regimen has been prescribed. How should the nurse respond? Select all that apply.

"Intestinal absorption will improve." "There will be less abdominal cramping." Fluids and electrolytes will not be depleted."

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? Select all that apply.

Anorexia Hemiplegia History of diabetes Urinary incontinence

Which instructions should the nurse include in the teaching plan for a client who will be taking simvastatin (Zocor) when discharged? Select all that apply.

Avoid prolonged exposure to the sun. Schedule regular ophthalmic examinations. Contact your health care provider if skin becomes gray-bronze.

What interventions should the nurse anticipate will be prescribed for a client who has a leak of the thoracic duct following radical neck surgery? Select all that apply.

Bed rest to conserve energy Chest tube to drain the fluid Total parenteral nutrition (TPN) to boost immune defenses

A nurse is teaching a class of expectant parents about changes that are to be expected during pregnancy. What changes does the nurse explain result from the melanocyte-stimulating hormone? Select all that apply.

Chloasma/Linea nigra.

A client is taught how to recognize indications of a hypoglycemic reaction. Which signs and symptoms identified by the client indicate to the nurse that the teaching was effective? Select all that apply.

Fatigue Weakness Nervousness Increased perspiration

A health care provider diagnoses a client with acute cholecystitis with biliary colic. What clinical findings should the nurse expect when performing a health history and physical assessment? Select all that apply.

Intolerance to foods high in fat Pain in the upper right quadrant of the abdomen

The nurse is obtaining a health history from a client with endometriosis. What consequences can occur as a result of this disorder? Select all that apply.

Metrorrhagia/ Ovarian cancer/Bowel strictures/Voiding difficulties.

A client with a large fetus is to have a pudendal block during the second stage of labor. What does the nurse plan to instruct the client about the effectiveness of the block? Select all that apply.

Perineal pain will not be felt/The bearing-down reflex will be diminished.

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

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

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply.

Rye Oats Wheat

A client appears at the clinic after getting a positive result on a home pregnancy test. She states that her last menstrual period began 10 weeks ago. The client expresses fear because she has been recently found to have syphilis. What prescriptions will the nurse expect to receive from the health care provider because of this information? Select all that apply.

Screening and testing of sexual partners/Intramuscular benzathine penicillin G, 2.4 million units, one dose.

A pregnant woman at 6 weeks' gestation tells the nurse at her first prenatal visit that she uses an over-the-counter herbal product as a health supplement that has been approved by the Food and Drug Administration. What should the nurse recommend to the client? Select all that apply.

Stop taking the supplement immediately. Discuss the use of the supplement with the practitioner. Discuss the use of any over-the-counter products with the practitioner.

Oxytocin (Pitocin) augmentation by way of intravenous piggyback is prescribed for a client in labor after a period of ineffective uterine contractions. What nursing interventions are most important if strong contractions that last 90 seconds or longer occur? Select all that apply.

Stopping the infusion Turning the client on her side Notifying the health care provider Verifying the duration of contractions

A client with Crohn's disease is admitted to the hospital with abdominal pain, fever, poor skin turgor, and diarrhea, with 10 stools in the past 24 hours. Which signs are evidence that the client probably is dehydrated? Select all that apply.

Sunken eyes Dry mucous membranes

The nurse is teaching a sex education course to high school students. What should the nurse teach them about why gonorrhea is difficult to control? Select all that apply:

Symptoms of the disease are vague/ The incubation period is relatively short/Causative organisms have become resistant to treatment.

A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply.

Tachycardia Restlessness Decreased urinary output

In the first 2 ½ hours after a radical neck dissection, 40 mL of medium red, bloody fluid is obtained from the client's drainage system. What should the nurse do? Select all that apply.

Take vital signs. Notify the health care provider.