hesi questions
which information would the nurse include in teaching a client who is advised to wear compression stockings for varicose veins? 1. put the stockings on at the first sign of discomfort 2. don the stockings before getting out of bed in the morning 3. ensure that the cuff of the stockings reaches the middle of the knees 4. substitute elastic bandages for compression stockings if they are more comfortable
2. don the stockings before getting out of bed in the morning
the nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. the nurse would include which information in the education? 1. purpose of bronchodilators 2. importance of meticulous oral hygiene 3. technique used in pursued lip breathing 4. methods used to maintain a dust free environment
2. importance of meticulous oral hygiene
which interventions would the nurse implement for a client with a ureteral calculus? select all that apply 1. limiting fluid intake at night 2. monitoring intake and output 3. straining the urine at each voiding 4. recording the client's blood pressure 5. administering the prescribed analgesic
2. monitoring intake and output 3. straining the urine at each voiding 5. administering the prescribed analgesic
after emptying the drainage collection chamber for a postoperative client's portable closed suction wound drainage device, how will the nurse create negative pressure in the system? 1. attaching the device to a wall suction unit 2. milking the tubing toward the suction device 3. compressing the device while closing the air plug 4. keeping the device in a position lower than the site of insertion
3. compressing the device while closing the air plug
a beta blocker is prescribed for a client with persistent ventricular tachycardia. which response indicates that the beta blocker is working effectively ? 1. decreased anxiety 2. reduced chest pain 3. decreased heart rate 4. increased blood pressure
3. decreased heart rate
which information about benign prostatic hyperplasia is important for the nurse to consider when caring for a client with that condition? 1. it is a congenital abnormality 2. a malignancy usually results 3. it predisposes to hydronephrosis 4. prostate specific antigen decreases
3. it predisposes to hydronephrosis
the nurse teaches a group of students about the function of the loop of henle. which function would the nurse include? 1. secretion of ammonia in the descending limb 2. secretion of hydrogen in the descending limb 3. reabsorption of sodium in the ascending limb 4. reabsorption of water in the ascending limb
3. reabsorption of sodium in the ascending limb
a client with a large calculus in the calyces of the right kidney has surgery scheduled for removal of the stone. which information would the nurse include when teaching postoperative care 1. the calculi are too large for transurethral removal 2. during the surgery, removal of the right ureter occurs 3. after surgery, a suprapubic catheter will be in place 4. after surgery, there will be a small incision in the right flank area
4. after surgery, there will be a small incision in the right flank area
which meal selection by a client on a 2 g sodium diet indicates that more diet teaching is needed? 1. soft cooked eff, toast, jelly, skim milk 2. baked chicken, boiled potatoes, broccoli and coffee 3. fillet of sole, baked potato, fresh fruit cup 4. cottage cheese, crackers, relish dish(celery, olives, sweet pickles )
4. cottage cheese, crackers, relish dish(celery, olives, sweet pickles )
which instruction would the nurse give to the client having a residual urine test? 1. void right after a urinary catheter is removed 2. collect a specimen of urine during midstream 3. attempt to void when a urinary catheter is in place 4. empty the bladder before a urinary catheter is inserted
4. empty the bladder before a urinary catheter is inserted - measures how much urine remains in the bladder after voiding
a client who has been told she needs a hysterectomy for cervical cancer reports being upset about being unable to have a third child. which action would the nurse take? 1. evaluate her willingness to pursue adoption 2. encourage her to focus on her own recovery 3. emphasize that she does have two children already 4. ensure that other treatment options for her are explored
4. ensure that other treatment options for her are explored
a client is admitted to the hospital with the diagnosis of cancer of the thyroid, and a thyroidectomy is scheduled. what is important for the nurse to consider when caring for this client during postoperative care? 1. hypercalcemia may result from parathyroid damage 2. hypotension and bradycardia may result from thyroid storm 3. tetany may result from underdosage of thyroid hormone replacement 4. hoarseness and airway obstruction may result from laryngeal nerve damage
4. hoarseness and airway obstruction may result from laryngeal nerve damage
which medication turns urine reddish- orange in color? 1. amoxicillin 2. ciprofloxacin 3. nitrofurantoin 4. phenazopyridine
4. phenazopyridine
which value is a normal vaginal pH? 1. 4.2 2. 6.8 3. 7.5 4. 9.3
4.2 (normal is 3.5-5)
which diagnostic test are used to measure kidney size? select all that apply 1. cystoscopy 2. cystography 3. radiography 4. cystourethrography 5. CT
-CT and radiography. -cystoscopy- used to identify abnormalities of the bladder wall in clients with kidney dysfunction - a cystography and cystourethrography are used to examine the structure of the urethra and to detect backward flow of urine
which statement explains why metabolic acidosis develops with kidney failure? 1. inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate 2. depressed rr due to metabolic wastes, causing CO2 retention 3. inability of the renal tubules to reabsorb water to dilute the acid contents of blood 4. impaired glomerular filtration, causing retention of sodium and metabolic waste products
1. inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
the nurse is teaching about pneumaturia to a coworker. which statement would the nurse include in the teaching plan? 1. it is the passage of urine containing gas 2. it is stinging pain in the urethral area 3. it is the diminished amount of urine in a given time 4. it is involuntary urination with increased pressure
1. it is the passage of urine containing gas
which action will the nurse take to check for subcutaneous emphysema in a client with a chest tube? 1. palpate around the tube insertion sites for crepitus 2. auscultate breath sounds for crackles and atelectasis 3. observe the client for the presence of a barrel- shaped chest 4. compare the length of inspiration with the length of expiration
1. palpate around the tube insertion sites for crepitus - occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes in the soft tissues.
which food would the nurse teach a client who has urinary phosphate calculi to include in the diet? 1. pear 2. beef 3. salmon 4. cheese
1. pear - all fresh fruits are low in phosphate
which action would the nurse take when a client reports pain and burning at a peripheral IV site after the nurse has flushed the saline lock with normal saline? 1. remove the IV catheter and restart the saline lock in another site 2. document the findings per protocol and reassess the site in 8 hours 3. flush the IV catheter and saline lock again vigorously with normal saline 4. change the dressing and apply a new clean dressing per IV care protocol
1. remove the IV catheter and restart the saline lock in another site
which antimicrobial medication acts on susceptible pathogens by inhibiting nucleic acid synthesis? 1. penicillin 2. actinomycin 3. erythromycin 4. cephalosporin
actinomycin
a client is scheduled for an adrenalectomy. which action would the nurse expect in the plan of care? 1. provide a low protein diet 2. administer parenteral corticosteroids 3. collect a preoperative 24 hour urine specimen 4. withhold all medications 48 hours before surgery
administer parenteral corticosteroids rationale- given IV or IM preop and continued intraop to prepare for acute adrenal insufficiency that follows surgery
the nurse reviews the prescriptions for the newly admitted emergency department client with urolithiasis. which order is the priority nursing action? 1. strain the client's urine 2. place the client in the high fowler's position 3. administer the prescribed morphine 4. collect a urine specimen for culture and sensitivity
administer the prescribed morphine- pain relief is the priority
which hormone influences kidney function? 1. renin 2. bradykinin 3. aldosterone 4. erythropoietin
aldosterone
prednisone is prescribed for a client with an exacerbation of colitis. which explanation would the nurse provide for administering prednisone? 1. the client will be protected from getting an infection 2. symptoms associated with the colitis will decrease slowly over time 3. although the medication causes anorexia, weight loss may not occur 4. although the medication decreases intestinal inflammation, it will not cure the colitis
although the medication decreases intestinal inflammation, it will not cure the colitis
a client has phosphate renal calculi. which food item would the nurse teach the client to include regularly in the diet? 1. apples 2. chocolate 3. rye bread 4. cheddar cheese
apples
a client reporting a recent bee sting presents with localized redness, swelling, intense localized pain, and itching. which action would the nurse implement? 1. applying cold compresses to the affected area 2. ensuring the client keeps the skin clean and dry 3. monitoring for neurological and cardiac symptoms 4. advising the client to launder all clothes with bleach
applying cold compresses to the affected area
which type of immunity will clients acquire through immunizations with live or killed vaccines? 1. natural active immunity 2. artificial active immunity 3. natural passive immunity 4. artificial passive immunity
artificial active immunity
a client with COPD is admitted to the hospital with a tentative diagnosis of pleuritis. it is important for the nurse to perform which intervention? 1. administer opioids frequently 2. assess for signs of pneumonia 3. give medication to suppress coughing 4. limit fluid intake to prevent pulmonary edema
assess for signs of pneumonia- prone to developing pneumonia bc of impaired lung expansion, air exchange, and drainage
during the administration of an antibiotic, the client becomes restless and flushed, and begins to wheeze. which action will the nurse take after stopping the antibiotic infusion? - check the client's temp - take the client's bp - obtain O2 stat - assess the client's resp status
assess the client's resp status
nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication? 1. pleural effusion 2. empyema 3. pneumothorax 4. atelectasis
atelectasis- occurs after general anesthesia bc of decreased resp depth and resulting collapse of alveoli
what is the most definitive test to confirm a diagnosis of multiple myeloma? 1. bone marrow biopsy 2. serum test for hypercalcemia 3. urine test for bence jones protein 4. X ray films of the ribs, spine, and skull
bone marrow biopsy
which organ is protected by microglial cells? 1. lung 2. liver 3. brain 4. kidney
brain
which term refers to the cowper gland? 1. skene gland 2. prostate gland 3. bartholin gland 4. bulbourethral gland
bulbourethral gland
which client has a higher risk for contracting the HIV infection? 1. a client who is involved in mutual masturbation 2. a client who undergoes voluntary prenatal HIV testing 3. a client who shares equipment to snort or smoke drugs 4. a client who engages in insertive sex with a noninfective partner
a client who shares equipment to snort or smoke drugs
which finding would the nurse expect when doing a respiratory assessment on a healthy young adult ? select all that apply 1. a midline trachea 2. deep pink nasal mucosa 3. deviated nasal septum 4. respirations of 14 breaths per minute 5. anteroposterior to lateral chest diameter ratio 2:1
a midline trachea deep pink nasal mucosa resp of 14 breaths per minute
which disorder is a primary glomerular disease? 1. diabetic glomerulopathy 2. chronic glomerulonephritis 3. hemolytic uremic syndrome 4. SLE
chronic glomerulonephritis
which characteristic of urine changes in the presence of a UTI? 1. clarity 2. viscosity 3. glucose level 4. specific gravity
clarity
which urine characteristic is consistent with a UTI? 1. smoky 2. cloudy 3. orange- amber 4. yellow- brown
cloudy
which finding during peritoneal dialysis would the nurse act on as a sign of infection? 1. pain with instillation 2. cloudy return of dialysate 3. complaints of constipation 4. leakage of dialysate around the catheter
cloudy return of dialysate
which complication would the nurse suspect in a client with genital herpes disease? 1. infertility 2. cold sores 3. reactive arthritis 4. bratholin abscess
cold sores
which component of the client's nephron acts as a receptor site for the ADH to regulate water balance? 1. collecting ducts 2. bowman capsule 3. distal convoluted tubule 4. proximal convoluted tubule
collecting ducts
which food selection indicates understanding of sources with high biologic value protein? 1. apple juice 2. raw carrots 3. cottage cheese 4. whole wheat bread
cottage cheese
which test provides information on bladder capacity, bladder pressure, and voiding reflexes? 1. radiography 2. renal arteriography 3. electromyography 4. cystometrography
cystometrography
which component of the client's nephron delivers blood from the glomerulus into the peritubular capillaries or the vasa recta? 1. arcuate artery 2. efferent arteriole 3. afferent arteriole 4. interlobular artery
efferent arteriole
which nursing action will help a client obtain maximum benefits after postural drainage? 1. administer oxygen 2. encourage coughing deeply 3. place the client in a sitting position 4. encourage the client to rest for 30 minutes
encourage coughing deeply- to promote expectoration of mucal secretions
which safety precaution would the nurse employ when assisting with the removal of a client's vaginal radium seeds? 1. clean the radium in ether or alcohol 2. wear foil- lined rubber gloves while handing the radium 3. ensure long forceps are available for removing the radium 4. document how long the radium seeds were in the vaginal vault
ensure long forceps are available for removing the radium
which leukocyte releases vasoactive amines during a client's allergic reaction? 1. neutrophil 2. monocyte 3. eosinophil 4. macrophage
eosinophil
which medication can be administered via the intramuscular route to treat anaphylaxis? 1. epinephrine 2. methdilazine 3. phenylephrine 4. mycophenolate mofetil
epinephrine
which virus is responsible for causing infectious mononucleosis in clients? 1. parvovirus 2. coronavirus 3. rotavirus 4. epstein barr virus
epstein barr virus
which decreased hormone level may cause a client's anemia? 1. bradykinin 2. prostaglandin 3. erythropoietin 4. activated vitamin D
erythropoietin
before a client with syphilis can be treated, which issue must be addressed? 1. portal of entry 2. size of chancre 3. existence of allergies 4. names of sexual contacts
existence of allergies
which condition is a result of clostridium botulinum? 1. upper respiratory tract infection 2. toxic shock syndrome 3. urinary tract infection 4. food poisoning with progressive muscle paralysis
food poisoning with progressive muscle paralysis
which action is characteristic of the hormone vasopressin? 1. produce concentrated urine 2. causes tubular secretion of sodium 3. promotes potassium secretion in the collecting duct 4. enhances sodium reabsorption in the distal convoluted tubule
helps produce concentrated urine
a client, transferred to the postanesthesia care unit after a transurethral resection of the prostate (TURP) has an IV line and a urinary retention catheter. during the immediate postop period for which potentially critical complication would the nurse monitor for? 1. sepsis 2. phlebitis 3. hemorrhage 4. leakage around urinary catheter
hemorrhage- common bc of venous oozing and bleeding from many small arteries in the area
a client reports swelling of the scrotum with no pain. which condition would the nurse anticipate in the client? 1. chancroid 2. hydrocele 3. spermatocele 4. incarcerated hernia
hydrocele
in which category of fluids would the nurse classify an IV infusion of 0.45 percent sodium chloride? 1. isotonic 2. isomeric 3. hypotonic 4. hypertonic
hypotonic
which test helps identify reproductive tract fibroids, tumors, and fistulas? 1. mammography 2. ultrasonography 3. hysterosalpingography 4. CT
hysterosalpingography
which dietary suggestion would the nurse provide while teaching a group of geriatric female clients who have reduced amounts of circulating estrogen? 1. include fish in your diet 2. include fruits in your diet 3. include yogurt in your diet 4. include legumes in your diet
include yogurt in your diet
randitine has been prescribed to help treat a client's gastric ulcer. the nurse expects this medication to act specifically by which mechanism? - inhibiting proton pumps - promoting the release of gastrin - regenerating the gastric mucosa - inhibiting the histamine at H2 receptors
inhibiting the histamine at H2 receptors
a client with hyperthyroidism is to receive methimazole. which information would the nurse provide? 1. initial improvement will take several weeks 2. few side effects are associated with this medication 3. this medication may be taken at any time during the day 4. large loading doses are used initially to normalize thyroid function
initial improvements will take several weeks
which assessment is necessary for the nurse to complete in a client with chronic kidney disease receiving loop diuretics? 1. hemoglobin levels 2. occurrence of nausea 3. presence of constipation 4. intake and output measurement
intake and output measurement
for clients experiencing an anaphylactic attack, which medication would the nurse initiate immediately? 1. isoproterenol 2. diphenhydramine HCL 3. hydrocortisone sodium succinate 4. methylprednisolone sodium succinate
isoproterenol
which part of the kidney produces the hormone bradykinin 1. kidney tissues 2. kidney parenchyma 3. renin producing granular cells 4. juxtaglomerular cells of the arterioles
juxtaglomerular cells of the arterioles
during a client's immediate postop period after a laryngectomy, which is a nursing priority? 1. provide emotional support 2. observe for signs of infection 3. keep the trachea free of secretions 4. promote a means of communication
keep the trachea free of secretions
which statement indicates the nurse has a correct understanding of kidney ultrasonography? 1. kidney ultrasonography makes use of iodinated contrast dye 2. kidney ultrasonography is performed on the client with an empty bladder 3. kidney ultrasonography makes use of sound waves and has minimal risk 4. kidney ultrasonography provides three dimensional info regarding kidneys
kidney ultrasonography makes use of sound waves and has minimal risk
which part of the female genitalia protects inner vulval structures and enhances sexual arousal? 1. clitoris 2. mons pubis 3. labia majora 4. bartholin glands
labia majora
a pathology report states a client's urinary calculus is composed of uric acid. which food item would the nurse instruct the client to avoid? 1. milk 2. liver 3. cheese 4. vegetables
liver
in which components of the nephron unit does furosemide decrease fluid reabsorption? select all that apply 1. glomerulus 2. loop of henle 3. distal tubules 4. proximal tubules 5. bowman's capsule
loop of henle, distal tubules, proximal tubules
the nurse is caring for a client who has had renal calculi secondary to hyperparathyroidism. which type of diet would the nurse teach the client? 1. low purine 2. low calcium 3. high phosphorus 4. high alkaline ash
low calcium
which hormone elevations indicate turner syndromes? 1. lutropin 2. prolactin 3. follitropin 4. testosterone 5. progesterone
lutropin and follitropin
which part of the kidney senses changes in blood pressure? 1. calices 2. glomerulus 3. macula densa 4. juxtaglomerular cells
macula densa
the nurse is notified that the latest potassium level for a client who has acute kidney injury is 6.2. which action would the nurse take? 1. alert the cardiac arrest team 2. call the lab to repeat the test 3. notify the primary health care provider 4. obtain an antiarrhythmic medication
notify the primary health care provider
which term would the nurse use to document a client experiencing urinary incontinence via involuntary loss of small amounts (25-35 ml) of urine from an overdistended bladder? 1. urge incontinence 2. stress incontinence 3. overflow incontinence 4. functional incontinence
overflow incontinence
a male client reported dysuria, nocturia and difficulty starting a urinary stream. the client has a cystoscopy and biopsy of the prostate gland scheduled. after the procedure, the client reports an inability to void. which action would the nurse implement? 1. insert a urinary catheter 2. palpate above the pubic symphysis 3. limit oral fluids until the client voids 4. assure the client that this is expected
palpate above the pubic symphysis- a full bladder is palpable with urinary retention and distention which are common problems after a cystoscopy because of urethral edema
which term is used for the tip of a pyramid in the kidney? 1. calyx 2. papilla 3. renal pelvis 4. renal column
papilla
which viral infection will cause the nurse to observe for warts on the hands, feet or genitals? 1. poxvirus 2. rhabdovirus 3. epstein- barr virus 4. papillomavirus
papillomavirus
which structures are included in the external genitalia of the male anatomy? 1. penis 2. testes 3. scrotum 4. urethra 5. seminal vesicles
penis and scrotum
which organism is responsible for causing dermatitis related to sexually transmitted infection 1. phthirus pubis 2. candida albicans 3. campylobacter jejuni 4. ureaplasma urealyticum
phthirus pubis
Which phase of a woman's sexual response is characterized by elevation of the uterus? 1. plateau phase 2. orgasmic phase 3. excitation phase 4. resolution phase
plateau phase
which term is used to describe a client passing air and bubbles during urination? 1. nocturia 2. oliguria 3. pneumaturia 4. stress incontinence
pneumaturia
which actin will the nurse take to support safe oral intake after tracheostomy? 1. include thin liquids 2. provide large meals 3. inflate the tracheostomy cuff fully 4. position client as upright as possible
position client as upright as possible
which serum laboratory value in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias? 1. calcium of 9.5 2. potassium of 7.02 3. bicarbonate of 22.8 4. phosphorus of 4.1
potassium of 7.02
the nurse is educating new parents about circumcision. which structure of the penis would the nurse tell the parents is removed during circumcision? 1. glans 2. prepuce 3. epididymis 4. vas deferens
prepuce
the nurse is providing postoperative care for a client who had kidney surgery reviews the client's urinalysis report. which urinary finding indicates the need to notify the primary health provider? 1. acidic PH 2. glucose negative 3. bacteria negative 4. presence of large proteins
presence of large proteins
the client with a suprapubic prostatectomy for cancer of the prostate has continuous bladder irrigations (CBI) in place after surgery. which primary goal is the nurse trying to achieve with CBI? 1. stimulate continuous formation of urine 2. facilitate the measurement of urinary output 3. prevent the development of clots in the bladder 4. provide continuous pressure on the prostatic fossa
prevent the development of clots in the bladder
the primary health provider suspects pituitary gland dysfunction in a female client. the nurse anticipates that which diagnostic test ill be prescribed? 1. estradiol test 2. prolactin test 3. sims- huhner test 4. papanicolaou (pap) test
prolactin test- used to detect pituitary gland dysfunction that causes amenorrhea
which part of the nephron secretes creatinine for elimination? 1. glomerulus 2. loop of henle 3. collecting duct 4. proximal tubule
proximal tubule
in which parts of the kidney are glucose and amino acids reabsorbed? 1. distal tubule 2. loop of henle 3. collecting duct 4. proximal tubule
proximal tubule- glucose, amino acids, electrolytes, and bicarbonate ions
which procedure involves the examination of the ureters and renal pelvises ? 1. cystogram 2. pyelogram 3. urethrogram 4. voiding cystourethrogram
pyelogram
a client is admitted to the emergency department with a stab wound to the chest. which is a priority nursing assessment? 1. level of pain 2. quality and depth of respirations 3. amount of serosanguinous drainage 4. blood pressure and pupillary response
quality and depth of respirations
which action is promoted by vasopressin? 1. sodium reabsorption 2. reabsorption of water 3. tubular secretion of sodium 4. red blood cell production
reabsorption of water-also known as ADH
which observation supports the nurse's suspicion that a client may have myoglobinuria? 1. red colored urine 2. brown colored urine 3. dark, amber colored urine 4. very pale, yellow colored urine
red colored urine
a client with rheumatoid arthritis asks the nurse why it is necessary to inject hydrocortisone into the knee joint. which reason would the nurse include in a response to this question? 1. lubricates the joint 2. reduces inflammation 3. provides physiotherapy 4. prevents ankylosis of the joint
reduces inflammation
the nurse is performing a male reproductive system assessment of an older adult client. the nurse expects which age- related finding? 1. asymmetrical testes 2. reducing size of testes 3. absence of pubic hair 4.foreskin that is difficult to retract
reducing size of testes
a client has a closed chest drainage system in place. how would the nurse determine the amount of chest tube drainage? 1. aspirate the drainage from the collection chamber 2. clamp the chest tube and empty the fluid from the collection chamber 3. refer to the date and time markings on the outside of the collection chamber 4. replacing the existing system with a new one to access drainage in the existing system
refer to the date and time markings on the outside of the collection chamber
which dietary modifications help improve the nutritional status of a client with acquired immunodeficiency syndrome? 1. refraining from consuming fatty foods 2. refraining from consuming frequent meals 3. refraining from consuming high calorie foods 4. refraining from consuming high protein foods
refraining from consuming fatty foods
which intervention would the nurse implement first when providing care for an older adult male client who is immobile and incontinent of urine? 1. restrict the client's fluid intake 2. regularly offer the client a urinal 3. apply incontinence pants 4. insert an indwelling catheter
regularly offer the client a urinal
the nurse is evaluating a client's understanding of peritoneal dialysis. which information in the client's response indicates understanding the purpose of the procedure? 1. reestablishing normal kidney functioning 2. cleaning the peritoneal membrane 3. providing fluid for intracellular spaces 4. removing toxins and metabolic wastes
removing toxins and metabolic wastes
after percussing a client's posterior chest and hearing low pitched hollow sounds over the whole chest, how will the nurse document the finding? 1. dull 2. flat 3. tympanic 4. resonance
resonance
which change in the ABGs would the nurse expect in a client with hyperventilation due to anxiety? 1. resp acidosis 2. resp alkalosis 3. resp compensation 4. resp decompensation
resp alkalosis- excess CO2 to be eliminated
a client with the diagnosis of inhalation anthrax is admitted to the ICU. it is most important for the nurse to make a focused assessment of which body system? 1. mental 2. hydration 3. respiratory 4. neurological
respiratory
which autoimmune disease can result in damage to the heart 1. uveitis 2. rheumatic fever 3. myasthenia gravis 4. graves disease
rheumatic fever
when encouraging a client to seek testing and treatment for streptococcal pharyngitis, which complication will the nurse discuss? 1. asthma 2. anemia 3. rheumatic fever 4. reye sydrome
rheumatic fever- caused by abnormal immunological response to group A beta hemolytic strep which may cause permanent scarring and damage to the heart valves
in which position will the nurse place a client who has been transferred from the postanesthetic care unit to the ICU after a radical neck dissection? 1. SIMS 2. lateral 3. high fowler 4. semi- fowler
semi fowler- helps maintain the head and neck in functional alignment and facilitates respirations bc the abdominal organs are not pressing against the diaphragm which allows the thoracic cavity to expand without resistance
which glands help in lubricating the female urinary meatus? 1. skene glands 2. prostate glands 3. cowper glands 4. bartholin glands
skene glands
for which condition is an adult client with a weakened urinary sphincter at risk? 1. bladder distention 2. skin irritation 3. tendency to fall 4. urinary retention
skin irritation
a client receiving a hemodialysis treatment asks the nurse which substances are being removed. which substance can the nurse report is being removed during hemodialysis? 1. blood 2. sodium 3. glucose 4. bacteria
sodium
which precaution would the nurse identify as a prevention for transmission of HIV and other bloodborne illnesses? 1. barrier 2. droplet 3. contact 4. standard
standard
Which sexually transmitted infection is associated with developing gummas? 1. chlamydia 2. trichomoniasis 3. gonorrhea 4. syphilis
syphilis
a client with ascites has a paracentesis and 1500 ml of fluid is removed. which clinical manifestation would indicate an immediate adverse response to the fluid removal? 1. tachycardia 2. decreased peristalsis 3. respiratory congestion 4. fever
tachycardia - fluid shifts from the intravascular compartment into the abdominal cavity causing hypovolemia
the nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. which is the most important intervention for the nurse to include in this plan? 1. ensuring sufficient rest 2. changing lifestyle routines 3. breathing clean outdoor air 4. taking medications as prescribed
taking medications as prescribed
which statement reflects the nurse's suspicions regarding a client's cloudy urine noted on a urinalysis report? 1. the client has a urinary infection 2. the client has a biliary obstruction 3. the client has diabetic ketoacidosis 4. the client has been on a starvation diet
the client has a urinary infection
which information would the nurse include when teaching about why women are more susceptible to urinary tract infections than men? 1. inadequate fluid intake 2. poor hygiene practices 3. the length of the urethra 4. the disruption of mucous membranes
the length of the urethra
before examination, the rn provides education for a student nurse regarding the gross anatomy and physiology of the the kidneys. which statement made by the student nurse indicates the need for additional teaching? 1. the right kidney is a little longer and narrower than the left kidney 2. the existence of three kidneys with normal kidney function is normal 3. the presence of a single kidney with normal kidney function is normal 4. the urinary bladder lies directly behind the pubic bone
the right kidney is a little longer and narrower than the left kidney- exact opposite is true
which collecting structure is located at the end of the renal papilla? 1. calyx 2. capsule 3. renal cortex 4. renal columns
calyx
which laboratory values would the nurse assess when preparing a client for a renal biopsy? select all that apply 1. hematocrit 2. hemoglobin 3. platelet count 4. pt and INR 5. PTT
1. hematocrit 2. hemoglobin 3. platelet count 4. pt and INR 5. PTT
nitroglycerine sublingual tabs are prescribed for a client with the diagnosis of angina. the nurse advises the client to anticipate pain relief to begin within which period of time? 1. 1 to 3 minutes 2. 4 to 5 seconds 3. 30-45 seconds 4. 10 to 15 minutes
1 to 3 minutes- rapid onset of action
after teaching a post radiation therapy client regarding proper skin care to the treatment area, which client statements indicate understanding? select all that apply 1. I will wear loos fitting clothing over the area 2. I will avoid using adhesive bandages 3. I will avoid exposing the area to cold temperatures 4. i will avoid rinsing the area with saline solution 5. I will use lotions to moisten the area when wearing makeup
1. I will wear loos fitting clothing over the area 2. I will avoid using adhesive bandages 3. I will avoid exposing the area to cold temperatures
a client is prescribed phenytoin for seizure control. which instruction about phenytoin will the nurse provide during discharge teaching? 1. antiseizure medications will probably be continued for life 2. phenytoin prevents any further occurrence of seizures 3. this medication needs to be taken during periods of emotional stress 4. your antiseizure medication usually can be stopped after a year's absence of seizures
1. antiseizure medications will probably be continued for life
which clinical finding would the nurse expect when caring for a client who has thrombophlebitis of the left lower leg? 1. edema of the left calf 2. weakness of the left foot 3. positive left sided babinski reflex 4. absence of left dorsalit pedis pulse
1. edema of the left calf
which processes are functions of ADH; select all that apply 1. controlling calcium balance 2. increasing arteriole constriction 3. increasing tubular permeability to water 4. stimulating the bone marrow to make red blood cells 5. promoting sodium reabsorption in the distal convoluted tubule
2,3
when a client develops epistaxis, which action would the nurse take? 1. tilt the head backward 2. pack the nose with tissue 3. apply direct lateral pressure to the nose 4. instruct the client to blow the nose gently
3. apply direct lateral pressure to the nose
which information would the nurse include in response to a client's questioning a protein restricted dietary change required for his or her acute kidney injury? 1. a high protein intake ensures an adequate daily supply of amino acids to compensate for losses 2. essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis 3. this diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys 4. currently, your body is unable to synthesize amino acids, so the nitrogen or amino acid synthesis must come from the dietary protein
3. this diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys
which laboratory test will be evaluated in a client with inflammatory arthritis? 1. leukocyte count 2. hemoglobin and hematocrit 3. blood urea nitrogen and creatinine 4. ESR
ESR
the nurse is educating a couple concerning the process of fertilization. which hormone would the nurse explain as stimulating the release of estrogen and progesterone after fertilization? 1. inhibin 2. testosterone 3. follicle stimulating hormone (FSH) 4. human chorionic gonadotropin (hCG)
HCG
a client fears pregnancy despite the use of oral contraceptives. the nurse anticipates that which blood test will be prescribed? 1. prolactin test 2. testosterone test 3. progesterone test 4. HCG test
HCg test
the nurse provides education about self care management to a client who was recently diagnosed with emphysema. the nurse concludes that further teaching is needed when the client makes which statement? 1. I will try to avoid smoking 2. i will maintain complete bedrest 3. I will control the temperature in my home 4. ill need to clean my mouth several times a day
I will maintain complete bedrest
a client is undergoing diagnostic testing for myasthenia gravis. which test would the nurse identify as the most specific for this diagnosis? 1. electromyography 2. pyridostigmine test 3. edrophonium chloride test 4. history of physical deterioration
edrophonium chloride test
which malnourished condition may predispose a client to secondary immunodeficiency 1. cachexia 2. cirrhosis 3. diabetes mellitus 4. hodgkin lymphoma
cachexia
the nurse is evaluating the results of treatment with erythropoietin. which assessment finding indicates improvement in the underlying condition being treated? 1. 2+pedal pulses 2. decreased pallor 3. decreased jaundice 4. 2+ DTR
decreased pallor
when a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest? 1. crackling 2. wheezing 3. decreased sounds 4. vesicular sounds
decreased sounds
which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator? 1. is able to obtain pulse ox readings 2. demonstrates use of a metered dose inhaler 3. know the health care provider's office hours 4. can identify triggers that may cause wheezing
demonstrates use of a metered dose inhaler
which conclusion would the nurse make about the assessment finding of a client's very pale yellow colored urine? 1. dilute urine 2. hematuria 3. concentrated urine 4. myoglobinuria
dilute urine
Which report by the client post transrectal prostate biopsy needs to be communicated to the health care provider as a possible sign of infection? 1. soreness 2. rust colored semen 3. light rectal bleeding 4. discharge from the penis
discharge from the penis
which intervention would the nurse suggest to promote comfort for a client experiencing pain during urination? 1. sitz baths 2. drinking water 3. leaning forward while sitting up 4. pouring cold water over the perineum
drinking water
which skin condition would the nurse expect when performing a physical assessment on a client with a history of hypothyroidism? 1. dry 2. moist 3. flushed 4. smooth
dry
which medication strengthens the urinary sphincters? 1. midodrine 2. duloxetine 3. oxybutynin 4. mirabegron
duloxetine- SNRI-
which symptoms are common during the fulminant stage of inhalation of anthrax. select all that apply 1. dyspnea 2. dry cough 3. diaphoresis 4. mild chest pain 5. high temperature
dyspnea diaphoresis high temperature
which bacteria colonies are commonly found in a client's large intestine? 1. e coli 2. N gono 3. s. aureus 4. H influenza
e coli
after teaching a family member how to administer subcutaneous enoxaparin sodium, how will the nurse evaluate the effectiveness of the training? 1. return demonstration on a manikin 2. verbalization of the side effects of the medication 3. observing the family member administering enoxaparin to the client 4. correctly verbalizing all necessary steps in enoxaparin sodium administration
observing the family member administering enoxaparin to the client
a client in a nursing home is diagnosed with urethritis. what would the nurse expect to do before initiating antibiotic therapy prescribed by the primary health care provider? 1. start a 24 hour urine collection 2. prepare for urinary catheterization 3. teach the client how to perform perineal care 4. obtain a specimen for culture and sensitivity
obtain a specimen for culture and sensitivity
A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? 1 Supine 2 Orthopneic 3 Low-Fowler 4 Semi-Fowler
orthopneic- sitting position that permits maximum lung expansion for gaseous exchange and enables the client to press the lower chest or abdomen against the overbed table which increases pressure on the diaphragm to help with exhalation, reducing residual volume
a client with chronic kidney disease selects treatment using continuous ambulatory peritoneal dialysis. which statement indicates the client's understands the purpose of this therapy? 1. the treatment provides continuous contact of dialyzer and blood to clear toxins by ultrainfiltration 2. the treatment exchanges and cleanses blood by correction of electrolytes and excretion of creatinine 3. the treatment decreases the need for immobility because the fluids clear the toxins in short and intermittent periods 4. the treatment uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion
the treatment uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion
which clinical indicator would the nurse monitor to determine if the client's simvastatin is effective? 1. heart rate 2. triglycerides 3. blood pressure 4. INR
triglycerides rationale- decreased levels of triglycerides, LDL and cholesterol
when assessing a client during peritoneal dialysis, the nurse observes that drainage of the dialysate from the peritoneal cavity has ceased before the required volume has returned. which instruction would the nurse give to the client? 1. drink a glass of water 2. turn from side to side 3. deep breath and cough 4. rotate the catheter periodically
turn from side to side - change position of the catheter, thereby freeing the drainage holes of the tubing which may be obstructed
which indicators of a developing infection would the nurse teach to the male client who has had a ureterolithotomy? 1. urgency or frequency of urination 2. an increase of ketones in the urine 3. the inability to maintain an erection 4. pain radiating to the external genitalia
urgency or frequency of urination
which action would the nurse implement when providing care for a client with acquired immunodeficiency syndrome (AIDS) 1. use standard precautions 2. employ airborne precautions 3. plan interventions to limit direct contact 4. discourage long visits from family members
use standard precautions
to reduce the incidence of HIV transmission, which basic strategies would the nurse teach a health class? 1. using condoms 2. using separate toilets 3. practicing sexual abstinence 4. preventing direct casual contacts 5. sterilizing the household utensils
using condoms and practicing sexual absinences
which surgeries are associated with permanent contraception? select all that apply 1. vasectomy 2. cryosurgery 3. mastectomy 4. varicocelectomy 5. tubal ligation
vasectomy and tubal ligation
which instruction would the nurse include in a health practices teaching plan for a female client with a history of recurrent urinary tract infections? 1. wear cotton underwear or lingerie 2. void at least every 6 hours around the clock 3. increase foods containing alkaline ash in the diet 4. wipe the perineum from back to front
wear cotton underwear or lingerie
which virus can cause encephalitis in adults and children? 1. rubella 2. parvovirus 3. rotaviruses 3. west nile virus
west nile virus