MED SURG EXAM Take 1

Metoprolol (Toprol-XL) is prescribed for a client with hypertension. For which side effect should the nurse monitor the client? 1 Hirsutism 2 Bradycardia 3 Restlessness 4 Hypertension

2 Bradycardia

A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition? (Select all that apply.) 1 Convulsions 2 Muscle spasms 3 Deep bone pain 4 Tingling of extremities 5 Depressed deep tendon reflexes

3 Deep bone pain 5 Depressed deep tendon reflexes

A client has undergone surgery with general anesthesia. Within how many hours after surgery should the nurse notify the health care provider if the client does not void? 1 4 hours 2 8 hours 3 12 hours 4 16 hours

Correct2 8 hours

A client is diagnosed with calcium oxalate renal calculi. Which nutrients should the nurse teach the client to avoid?(Select all that apply.) 1 Milk 2 Nuts 3 Liver 4 Spinach 5 Rhubarb

Correct2 Nuts Correct4 Spinach Correct5 Rhubarb

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.) 1 Pruritus 2 Oliguria 3 Tachycardia 4 Cloudy outflow 5 Abdominal pain

Correct3 Tachycardia Correct4 Cloudy outflow Correct5 Abdominal pain

A client with the diagnosis of osteogenic sarcoma has metastasis to the lung. Which client statement about the concept of metastasis indicates a need for further instruction? 1 "I'm upset to know that the tumor may metastasize to my bones." 2 "I didn't realize that I could have metastasis without having pain." 3 "I can have metastasis to other parts of my body besides the lung." 4 "I need to talk with my doctor about the possibility of more metastases."

1 "I'm upset to know that the tumor may metastasize to my bones."

A client has chronic asthma. For which complication should the nurse monitor this client? 1 Atelectasis 2 Pneumothorax 3 Pulmonary edema 4 Respiratory alkalosis

1 Atelectasis

A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an occasional premature atrial contraction (PAC). What action should the nurse take? 1 Continue to monitor the client. 2 Notify the health care provider. 3 Ensure that a defibrillator is close by. 4 Administer lidocaine intravenously as per protocol

1 Continue to monitor the client

A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" From this statement the nurse determines that the client most likely is experiencing: 1 Fear 2 Depression 3 Dependency 4 Ambivalence

1 Fear

A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery? 1 "Urinary control may be permanently lost to some degree." 2 "An indwelling urinary catheter is required for at least a day." 3 "Your ability to perform sexually will be impaired permanently." 4 "Burning on urination will last while the cystotomy tube is in place."

2 "An indwelling urinary catheter is required for at least a day."

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do tobest help this client? 1 Determine the client's emotional state. 2 Give prescribed drugs to promote bronchiolar dilation. 3 Provide education about the impact of a family history. 4 Encourage the client to use an incentive spirometer routinely

2 Give prescribed drugs to promote bronchiolar dilation

A client develops increased respiratory secretions because of radiation therapy to the lung, and the health care provider prescribes postural drainage. What client assessment leads the nurse to determine that the postural drainage is effective? 1 Is free of crackles 2 Has a productive cough 3 Is able to expectorate saliva 4 Can breathe deeply through the nose

2 Has a productive cough

The nurse concludes that a client with type 1 diabetes is experiencing hypoglycemia. Which responses support this conclusion? (Select all that apply.) 1 Vomiting 2 Headache 3 Tachycardia 4 Cool clammy skin 5 Increased respirations

2 Headache 3 Tachycardia 4 Cool clammy skin

A nurse is assessing a newly admitted client with a pressure ulcer indicated in the image. What stage pressure ulcer should the nurse document on the admission history and physical? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

2 Stage II

8. An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective? 1 A reduction of confusion 2 An activated partial thromboplastin (APTT) twice the usual value 3 An absence of ecchymotic areas 4 A decreased viscosity of the blood

2. An activated partial thromboplastin (APTT) twice the usual value

A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse? 1 "Your perception of the diagnostic test is incorrect." 2 "I will ask the primary health care provider to clarify the diagnostic procedure." 3 "Tell me more about the conversation you had with your health care provider." 4 "The procedure will be fast so that you will experience minimal discomfort."

3 "Tell me more about the conversation you had with your health care provider."

Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the client's nasogastric tube is bright red. What should the nurse do first? 1 Notify the health care provider. 2 Clamp the nasogastric tube for one hour. 3 Determine that this is an expected finding. 4 Irrigate the nasogastric tube with iced saline.

3 Determine that this is an expected finding

For which classic clinical finding should the nurse assess the stool of clients with malabsorption syndrome? 1 Melena 2 Frank blood 3 Fat globules 4 Currant jelly consistency

3 Fat globules

Nursing intervention for a client who is hyperventilating should focus on providing reassurance and: 1 Administering oxygen 2 Using an incentive spirometer 3 Having the client breathe into a paper bag 4 Administering an IV containing bicarbonate ions

3 Having the client breathe into a paper bag

After a bilateral inguinal hernia repair (herniorrhaphy) the nurse should assess the client for the development of: 1 Hydrocele 2 Paralytic ileus 3 Urinary retention 4 Thrombophlebitis

3 Urinary retention

A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse considers that a distinguishing sign that is unique to a fat embolus is: 1 Oliguria 2 Dyspnea 3 Petechiae 4 Confusion

3. Petechiae

A client with hypertension is to follow a 2-gram sodium diet. Which client statement provides evidence that the nurse's dietary instructions are understood? 1 "My fluid intake should be restricted." 2 "I should limit the number of daily food servings." 3 "Salt should not be used during cooking but can be used at the table." 4 "Labels on prepackaged food products should be evaluated before purchase."

4 "Labels on prepackaged food products should be evaluated before purchase."

The nurse is caring for a client two days after the client had a brain attack (CVA). To prevent the development of plantar flexion, the nurse should: 1 Place a pillow under the thighs 2 Elevate the knee gatch of the bed 3 Encourage active range of motion 4 Maintain the feet at right angles to the legs

4 Maintain the feet at right angles to the legs

A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? 1 Retrospective 24-hour calorie count 2 Elimination pattern during the last 30 days 3 Complete gynecological and sexual history 4 Presence of a cough and pulmonary secretions

4 Presence of a cough and pulmonary secretions

A client has a diagnosis of hemorrhoids. Which signs and symptoms does the nurse expect the client to report? (Select all that apply.) 1 Flatulence 2 Anal itching 3 Blood in stool 4 Rectal pressure 5 Pain when defecating

Anal itching Blood in stool Rectal pressure Pain when defecating

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.) 1 Carrots 2 Oranges 3 Tomatoes 4 Skim milk 5 Leafy greens

Carrots Leafy greens

A nurse is caring for a client with Addison disease. What should the nurse teach the client to do regarding an appropriate diet? 1 Add extra salt to food 2 Limit intake to 1200 calories 3 Omit protein foods at each meal 4 Restrict the daily intake of fluids to 1 L

Correct1 Add extra salt to food

A client who had a lithotripsy for a renal calculus is to be discharged from the hospital. What should the nurse include in the home care instructions? 1 Drink at least 3 L of fluid daily for four weeks 2 Eliminate organ meats from the diet for six weeks 3 Increase the Increase the intake of dairy products for five days 4 Restrict movement for three days before resuming usual activities

Correct1 Drink at least 3 L of fluid daily for four weeks

A nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client? 1 Highly contagious 2 Caused by a fungus 3 Chronic with exacerbations 4 Associated with other allergies

Correct1 Highly contagious

A client who is to receive radiation for cancer says to the nurse, "My family and friends say that I will get a radiation burn." The best response by the nurse is: 1 "It will be no worse than a sunburn." 2 "A localized skin reaction usually occurs." 3 "Daily application of an emollient will prevent the burn." 4 "They may be misinformed."

Correct2 "A localized skin reaction usually occurs."

A nurse is assessing the urine of a client with a urinary tract infection. What appearance should the nurse expect this client's urine to have? 1 Smoky 2 Cloudy 3 Orange-amber 4 Yellow-brown

Correct2 Cloudy

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.) 1 Polyuria 2 Jaundice 3 Azotemia 4 Hypertension 5 Polycythemia

Correct3 Azotemia Correct4 Hypertension

A client in a debilitated state is admitted for palliative treatment of cancer of the liver. Which objective information collected by the nurse is most helpful for future monitoring of the client's condition? 1 Diet history 2 Bowel sounds 3 Present weight 4 Pain description

Correct3 Present weight

A client is a candidate for intubation as a result of bleeding esophageal varices. Which type of tube should the nurse anticipate will most likely be used to meet the needs of this client? 1 Levin 2 Salem sump 3 Miller-Abbott 4 Blakemore-Sengstaken

Correct4 Blakemore-Sengstaken

The nurse should ask the client with secondary syphilis about sexual contacts during the past: 1 21 days 2 30 days 3 Three months 4 Six months

Correct4 Six months

When assessing a wound that is healing by secondary intention, the nurse can classify it according to its condition and color. How should the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate? 1 Red 2 Black 3 Green 4 Yellow

Correct4 Yellow

A nurse instructs a client with a history of frequent urinary tract infections to drink cranberry juice to: 1 Decrease the urinary pH 2 Exert a bactericidal effect 3 Improve glomerular filtration 4 Relieve the symptoms of dysuria

Decrease the urinary pH

A client is diagnosed as having colitis. Which clinical findings should the nurse expect the client to report? (Select all that apply.) 1 Fever 2 Diarrhea 3 Gain in weight 4 Spitting up blood 5 Abdominal cramps

Diarrhea Abdominal cramps

A client with myasthenia gravis who is taking a cholinesterase inhibitor is admitted to the emergency department in crisis. To distinguish between myasthenic crisis and cholinergic crisis, the nurse expects the health care provider to prescribe: 1 Atropine sulfate 2 Protamine sulfate 3 Naloxone (Narcan) 4 Edrophonium chloride (Tensilon)

Edrophonium chloride (Tensilon)

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.) 1 More rapid action results. 2 They are ineffective orally. 3 They decrease colon irritability. 4 Intestinal absorption may be inadequate. 5 Allergic responses are less likely to occur.

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

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.) 1 Nausea 2 Lethargy 3 Bradycardia 4 Polycythemia 5 Emotional changes

Nausea Emotional changes

A client has a nasogastric feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. What should the nurse do first? 1 Instill normal saline into the tube to maintain patency. 2 Obtain an x-ray to verify that the tube is in the stomach. 3 Auscultate the epigastric area while instilling 15 mL of air. 4 Withdraw 30 mL of stomach contents to verify tube placement

Obtain an x-ray to verify that the tube is in the stomach

A client is admitted to the hospital for surgery for recto-sigmoid colon cancer, and the nurse is obtaining a health history as part of the admission process. What clinical findings associated with recto-sigmoid colon cancer does the nurse expect the client to report? (Select all that apply.) 1 Rectal bleeding 2 Inability to digest fat 3 Change in the shape of stools 4 Feeling of abdominal bloating

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

A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end stage renal disease (ESRD)? 1 Fluid 2 Protein 3 Sodium 4 Potassium

Correct2 Protein

Which factor identified by the nurse while obtaining the client's health history predisposes a client to type 2 diabetes? 1 Having diabetes insipidus 2 Eating low cholesterol foods 3 Being twenty pounds overweight 4 Drinking a daily alcoholic beverage

Correct3 Being twenty pounds overweight

Which insulin should the nurse prepare for the emergency treatment of ketoacidosis? 1 Glargine (Lantus) 2 NPH insulin (Novolin N) 3 Insulin aspart (NovoLog) 4 Insulin detemir (Levemir)

Correct3 Insulin aspart (NovoLog)

A client is admitted to the hospital with severe flank pain, nausea, and hematuria caused by a ureteral calculus. A lithotripsy is scheduled. What should be the nurse's initial intervention? 1 Strain all urine output. 2 Increase oral fluid intake. 3 Obtain a urine specimen for culture. 4 Administer the prescribed analgesic

Correct4 Administer the prescribed analgesic

Which nursing action can best prevent infection from a urinary retention catheter? 1 Cleansing the perineum 2 Encouraging adequate fluids 3 Irrigating the catheter once daily 4 Cleansing around the meatus routinely

Correct4 Cleansing around the meatus routinely

Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with this autosomal recessive disorder: 1 Cerebral palsy 2 Cystic fibrosis 3 Muscular dystrophy 4 Multiple sclerosis

2 Cystic fibrosis

A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion? 1 History of hypertensive disease 2 Emboli associated with atrial fibrillation 3 Developmental defect of the arterial wall 4 Inappropriate paroxysmal neural discharge

2 Emboli associated with atrial fibrillation

A nurse is caring for a client who had a total hip replacement. What nursing action should be incorporated into the plan of care to prevent thrombus formation? 1 Turning the client from side to side 2 Encouraging the client to perform ankle exercises 3 Getting the client up to sit in a chair for as long as tolerated 4 Ambulating the client when the effects of anesthesia subside

2 Encouraging the client to perform ankle exercises

A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals and recommends: 1 Meatloaf and tea 2 Meatloaf and strawberries 3 Chicken soup and baked apple 4 Chicken soup and buttered bread

2 Meatloaf and strawberries

A client is prescribed prolonged bed rest after surgery. Which complication does the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space? 1 Cerebral embolism 2 Pulmonary embolism 3 Dry gangrene of a limb 4 Coronary vessel occlusion

2 Pulmonary embolism

A client with a history of cardiac dysrhythmias is admitted to the hospital with dehydration. What does the nurse expect to be listed on the client's plan of care? 1 A glass of water every hour until hydrated. 2 Small, frequent intake of juices, broth, or milk. 3 Short-term nasogastric (NG) replacement of fluids and nutrients. 4 A rapid intravenous (IV) infusion of an electrolyte and glucose solution

2 Small, frequent intake of juices, broth, or milk

A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly? 1 Bananas 2 Strawberries 3 Green beans 4 Sweet potatoes

2 Strawberries

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics? 1 Oral 2 Topical 3 Intravenous 4 Intramuscular

2 Topical

A nurse is caring for a client with full-thickness burns of the anterior trunk and thigh. During the first two to three days after the burn to monitor fluid balance, it is important for the nurse to assess the: 1 Weight every day 2 Urinary output every hour 3 Blood pressure every 15 minutes 4 Extent of peripheral edema every four hours

2 Urinary output every hour

To determine the status of a client's carotid pulse, the nurse should palpate: 1 Below the mandible 2 In the lateral neck region 3 Along the clavicle at the base of the neck 4 At the anterior neck, lateral to the trachea

4 At the anterior neck, lateral to the trachea

A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase? 1 Alleviate pain 2 Prevent infection 3 Replace blood loss 4 Restore fluid volume

4 Restore fluid volume

A health care provider prescribes bisacodyl (Dulcolax) for a client with cardiac disease. The nurse explains to the client that this drug acts by: 1 Producing bulk 2 Softening feces 3 Lubricating feces 4 Stimulating peristalsis

4 Stimulating peristalsis

The client is receiving multiple blood transfusions after having extensive abdominal surgery. If the client develops fever, chills, and lower back pain, and seems very nervous, what will be the nurse's first action? 1 Notify the blood bank 2 Notify the health care provider 3 Reduce the rate of the blood transfusion 4 Stop the blood and infuse normal saline

4 Stop the blood and infuse normal saline

A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. The nurse determines that further teaching is necessary when the client states that to avoid skin irritation and breakdown the client will: 1 Leave the skin markings intact 2 Protect the skin from sources of heat 3 Wear soft clothing over the upper body 4 Use an oatmeal-based lotion after each treatment

4 Use an oatmeal-based lotion after each treatment

A client with chronic liver disease reports, "My gums have been bleeding spontaneously." The nurse identifies small hemorrhagic lesions on the client's face. The nurse concludes that the client needs additional: 1 Bile salts 2 Folic acid 3 Vitamin A 4 Vitamin K

4 Vitamin K

Despite receiving 2900 mL intake for two days, the client's urine output has progressively diminished. The nurse identifies that the urinary output is less than 40 mL/hr over the past three hours. What action should the nurse take? 1 Assess breath sounds and obtain vital signs 2 Decrease the intravenous (IV) flow rate and increase oral fluids 3 Insert an indwelling catheter to facilitate emptying of the bladder 4 Check for dependent edema by assessing the lower extremities

Correct1 Assess breath sounds and obtain vital signs

A client is diagnosed as having kidney failure. During the oliguric phase the nurse should assess the client for: 1 Hyperkalemia 2 Hypocalcemia 3 Hypernatremia 4 Hypoproteinemia

Correct1 Hyperkalemia

A client with burns tells the nurse that the primary health care provider stated that skin grafts would be required. The client asks when the procedure will be performed. The most appropriate nursing response is: 1 "The procedure will be performed within seven days." 2 "Tell me what your primary health care provider said about the graft procedure." 3 "The graft procedure will be done as soon as scar formation occurs." 4 "It depends on when you are rid of all signs of infection."

Correct2 "Tell me what your primary health care provider said about the graft procedure."

The health care provider prescribes daily fasting blood glucose levels for a client with diabetes mellitus. The goal of treatment is that the client will have glucose levels within the range of: 1 40 to 65 mg/dL of blood 2 70 to 105 mg/dL of blood 3 110 to 145 mg/dL of blood 4 150 to 175 mg/dL of blood

Correct2 70 to 105 mg/dL of blood

When a client returns from the postanesthesia care unit after a kidney transplant, the nurse should plan to measure the client's urinary output every: 1 15 minutes 2 One hour 3 Two hours 4 Three hours

Correct2 One hour

A client who has been on hemodialysis for several weeks asks the nurse what substances are being removed by the dialysis. The nurse informs the client that one of the substances passing through the membrane is: 1 Blood 2 Sodium 3 Glucose 4 Bacteria

Correct2 Sodium

A client is hospitalized with joint pain, loss of hair, yellow pigmentation of the skin, and an enlarged liver. The nurse suspects what type of toxicity? 1 Thiamine 2 Vitamin A 3 Vitamin C 4 Pyridoxine

Correct2 Vitamin A

A client with a diagnosis of tuberculosis is receiving isoniazid (INH) as part of a chemotherapy protocol. The nurse assesses the client for adverse responses to the medication. The nurse determines that prompt intervention is needed for which client response? 1 Orange feces 2 Yellow sclera 3 Temperature of 96.8° F 4 Weight gain of 5 pounds

Correct2 Yellow sclera

The nurse is caring for a client with a 25-year history of excessive alcohol use. The nurse expects that assessment findings will indicate: 1 Signs of liver infection 2 A low blood ammonia level 3 A small liver with a rough surface 4 An elevated temperature and a generalized rash

Correct3 A small liver with a rough surface

Before a client with syphilis can be treated, what should be determined? 1 Portal of entry 2 Size of chancre 3 Existence of allergies 4 Names of sexual contacts

Correct3 Existence of allergies

A nurse is assessing a client with the diagnosis of primary hypertension. What clinical finding does the nurse identify as an indicator of primary hypertension? 1 Mild but persistent depression 2 Transient temporary memory loss 3 Occipital headache in the morning 4 Cardiac palpitation during periods of stress

Correct3 Occipital headache in the morning

The nurse teaches a client with exophthalmos how to reduce discomfort and prevent corneal ulceration. Which plan reported by the client supports the nurse's conclusion that the teaching was effective? 1 "Eliminate excessive blinking." 2 "Not move my extraocular muscles." 3 "Keep the head of my bed elevated." 4 "Avoid using a sleeping mask at night."

Correct4 "Avoid using a sleeping mask at night

Which statement made by a 28-year-old client recently diagnosed with type 1 diabetes indicates that further education is necessary regarding the teaching plan? 1 "I will need to have my eyes and vision examined once a year." 2 "I will need to check my blood sugar at home to evaluate my response to my treatment plan." 3 "I can improve metabolic and cardiac risk factors of this disease if I follow a low-calorie diet and lose weight." 4 "Once I reach my target weight there is a good chance that I will be able to switch from insulin to an oral medication to control my blood sugar."

Correct4 "Once I reach my target weight there is a good chance that I will be able to switch from insulin to an oral medication to control my blood sugar."

A client with chronic kidney disease is admitted to the hospital with severe infection and anemia. The client is depressed and irritable. The client's spouse asks the nurse about the anticipated plan of care. What is an appropriate nursing response? 1 "The staff will provide total care because the infection causes severe fatigue." 2 "Mood elevators will be prescribed to improve depression and irritability." 3 "Iron will be prescribed for the anemia and the stools will be dark." 4 "The intake of meat, eggs, and cheese will be restricted so the kidneys can clear the body of waste products."

Correct4 "The intake of meat, eggs, and cheese will be restricted so the kidneys can clear the body of waste products."

A nurse is caring for a client who had a pneumonectomy. What is the priority nursing assessment? 1 Pulse oximetry 2 Ventilatory exchange 3 Closed-chest drainage 4 Approximation of the incision

2 Ventilatory exchange

A client had surgery on the shoulder and the nurse is to obtain a brachial pulse. Use the illustration to indicate where the nurse should palpate to best obtain the brachial pulse rate. 1 a 2 b 3 c 4 d

2 b

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.) 1 Polyuria 2 Polydipsia 3 Paralytic ileus 4 Serum glucose of 105 mg/dL 5 Respiratory rate of 16 breaths per minute

Correct1 Polyuria Correct2 Polydipsia

A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection because it resulted from: 1 Poor personal hygiene 2 A procedure performed at the hospital 3 Inadequate dietary intake 4 The client's developmental level

Correct2 A procedure performed at the hospital

A nurse plans an evening snack of milk, crackers, and cheese for an average-sized client who is receiving Humulin N insulin. What is the purpose of this snack? 1 Encouragement to stay on the diet 2 Food to counteract late insulin activity 3 Added calories to promote weight gain 4 High carbohydrates to provide nourishment for immediate use

Correct2 Food to counteract late insulin activity

The nurse is caring for a client with acute renal failure. The most serious complication for this client is: 1 Anemia 2 Infection 3 Weight loss 4 Platelet dysfunction

Correct2 Infection

A nurse reviews the history of a client who is hospitalized with a diagnosis of urinary calculi and identifies which factor may have contributed to the development of the calculi? 1 Increased fluid intake 2 Urine specific gravity of 1.017 3 History of hyperparathyroidism 4 Jogging 3 miles a day

Correct3 History of hyperparathyroidism

Which is the most serious complication for which the nurse must monitor a client with kidney failure? 1 Anemia 2 Weight loss 3 Hyperkalemia 4 Platelet dysfunction

Correct3 Hyperkalemia

A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. This should be documented in the medical record as: Incorrect1 Urge incontinence 2 Stress incontinence 3 Reflex incontinence 4 Overflow incontinence

Correct4 Overflow incontinence

A male client reports dysuria, nocturia, and difficulty starting the urinary stream. A cystoscopy and biopsy of the prostate gland have been scheduled. After the procedure the client reports an inability to void. The nurse should: 1 Limit oral fluids until the client voids 2 Assure the client that this is expected 3 Insert a urinary retention catheter 4 Palpate above the pubic symphysis

Correct4 Palpate above the pubic symphysis

After an amputation, a client's residual limb is bandaged snugly throughout the postoperative period. The nurse teaches the client that the primary purpose of the rigid bandaging of the residual limb is to: 1 Prevent suture line infection 2 Promote drainage of secretions 3 Prevent injury to the residual limb 4 Promote shrinkage of the distal end of the residual limb

Correct4 Promote shrinkage of the distal end of the residual limb

A client has a history of progressive carotid and cerebral atherosclerosis and experiences transient ischemic attacks (TIAs). The nurse explains to the client that TIAs are: 1 Temporary episodes of neurological dysfunction 2 Intermittent attacks caused by multiple small clots 3 Ischemic attacks that result in progressive neurological deterioration 4 Exacerbations of neurological dysfunction alternating with remissions

1 Temporary episodes of neurological dysfunction

A client's urine specific gravity is being measured. For what condition should the nurse conduct a focused assessment when a client's specific gravity is increased? 1 Fluid overload 2 Low-grade fever 3 Diabetes insipidus 4 Chronic kidney disease

2 Low-grade fever

A client with rheumatoid arthritis is to begin taking ibuprofen (Motrin) 800 mg by mouth three times a day. The nurse provides education about the medication's side effects. The nurse concludes that the teaching was effective when the client states: 1 "I need to have my blood work checked every month." 2 "I need to balance exercise with rest." 3 "I need to change positions slowly." 4 "I need to take the medication between meals.

Correct1 "I need to have my blood work checked every month."

A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. The nurse's best response is: 1 "This type of schedule gives noncancerous cells time to recover." 2 "The department only operates from Monday through Friday." 3 "Your energy level will be increased greatly by a five-day schedule." 4 "Side effects are eliminated when treatment is administered for five rather than seven days."

Correct1 "This type of schedule gives noncancerous cells time to recover."

During discharge teaching, a client with an ileal conduit asks how frequently the urine pouch should be emptied. The best reply by the nurse is: 1 "To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours." 2 "To prevent skin irritation, it should be emptied every hour if any urine has collected in the bag." 3 "To reduce the risk of infection, the system should be opened as little as possible; two times a day is adequate." 4 "To reduce the cost of drainage pouches, it should be emptied once the system is switched to a bedside collection bag."

Correct1 "To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours."

After a transurethral vaporization of the prostate, the client returns to the unit with an indwelling urinary catheter and a continuous bladder irrigation. The client puts the call light on to report the need to urinate. What should the nurse do first? 1 Assess that the tubing attached to the collection bag is patent 2 Obtain the client's vital signs 3 Explain that the balloon inflated in the bladder causes this feeling 4 Review the client's intake and output

Correct1 Assess that the tubing attached to the collection bag is patent

After a transurethral vaporization of the prostate, the client returns to the unit with an indwelling urinary catheter and a continuous bladder irrigation. The client puts the call light on to report the need to urinate. What should the nurse do first? 1 Assess that the tubing attached to the collection bag is patent 2 Obtain the client's vital signs 3 Explain that the balloon inflated in the bladder causes this feeling 4 Review the client's intake and output

Correct1 Assess that the tubing attached to the collection bag is patent

The nurse reviews the medical records of four male clients and concludes that the client that is at highest risk of developing prostate cancer is the: 1 Black 55-year-old 2 White 45-year-old 3 Asian 55-year-old 4 Hispanic 45-year-old

Correct1 Black 55-year-old

A client is admitted to the hospital for acute gastritis and ascites secondary to alcoholism and cirrhosis. It is mostimportant for the nurse to assess this client for: 1 Blood in the stool 2 Food intolerances 3 Complaints of nausea 4 Hourly urinary output

Correct1 Blood in the stool

The nurse is counseling a client with type 1 diabetes about the client's favorite foods that are lowest in carbohydrates (CHO). The nurse determines that this concept is understood when the client chooses eight ounces of: 1 Skim milk 2 Apple juice 3 Nonfat yogurt 4 Fresh orange juice

Correct1 Skim milk

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.) 1 Butterfly facial rash 2 Firm skin fixed to tissue 3 Inflammation of the joints 4 Muscle mass degeneration 5 Inflammation of small arteries

Correct1 Butterfly facial rash Correct3 Inflammation of the joints

A client is receiving patient-controlled analgesia (PCA) after surgery. The nurse determines that with this type of therapy the: 1 Client is able to self-administer pain-relieving drugs as necessary 2 Amount of medication received is determined entirely by the client 3 Amount of drug used for analgesia fluctuates greatly over a given period 4 Self-administration relieves the nurse of monitoring the client for pain relief

Correct1 Client is able to self-administer pain-relieving drugs as necessary

Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? (Select all that apply.) 1 Diarrhea 2 Listlessness 3 Weight loss 4 Bradycardia 5 Decreased appetite

Correct1 Diarrhea Correct3 Weight loss

A female client has a history of frequent urinary tract infections (UTIs). To decrease the incidence of the infections, the nurse instructs the client to increase fluid intake and: 1 Empty the bladder every three hours 2 Take warm bubble baths 3 Wipe from back to front 4 Take a prophylactic antibiotic after sexual intercourse

Correct1 Empty the bladder every three hours

The most essential nursing intervention for a client with a nephrostomy tube is to: 1 Ensure free drainage of urine 2 Milk the tube every two hours 3 Instill 2 mL of normal saline every eight hours 4 Keep an accurate record of intake and output

Correct1 Ensure free drainage of urine

During a routine clinic visit, an older adult complains about being unable to sleep well at night and then feeling sleepy throughout the next day. The nurse should advise the client to use what sleep promotion technique? 1 Exercise daily 2 Read in bed before sleeping 3 Avoid naps during the daytime 4 Have a hot cup of tea at bedtime

Correct1 Exercise daily

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.) 1 Fatigue 2 Dry skin 3 Insomnia 4 Intolerance to heat 5 Progressive weight loss

Correct1 Fatigue Correct2 Dry skin

A client is admitted to the hospital with diabetic ketoacidosis. The nurse identifies that the elevated ketone level present with this disorder is caused by the incomplete oxidation of: 1 Fats 2 Protein 3 Potassium 4 Carbohydrates

Correct1 Fats

A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound? 1 In the preoperative period 2 Two days before discharge 3 On the first postoperative day 4 During the first dressing change

Correct1 In the preoperative period

A nurse is caring for a client who is experiencing an underproduction of thyroxine (T4). Which client response is associated with an underproduction of thyroxine? 1 Myxedema 2 Acromegaly 3 Graves disease 4 Cushing disease

Correct1 Myxedema

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.) 1 Nonintention tremors 2 Frequent bouts of diarrhea 3 Masklike facial expression 4 Hyperextension of the neck 5 Low-pitched monotonous voice

Correct1 Nonintention tremors Correct3 Masklike facial expression Correct5 Low-pitched monotonous voice

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.) 1 Palpitations 2 Tachycardia 3 Thickened skin 4 Apathetic attitude 5 Menstrual disturbances

Correct1 Palpitations Correct2 Tachycardia

A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction? 1 Relieve muscle spasm and pain 2 Prevent contractures from developing 3 Keep the client from turning and moving in bed 4 Maintain the limb in a position of external rotation

Correct1 Relieve muscle spasm and pain

A client with type 1 diabetes comes to the clinic because of concerns regarding erratic control of blood glucose with the prescribed insulin therapy. The client has been experiencing a sudden fall in the blood glucose level, followed by a sudden episode of hyperglycemia. Which complication of insulin therapy should the nurse conclude that the client is experiencing? 1 Somogyi effect 2 Dawn phenomenon 3 Diabetic ketoacidosis 4 Hyperosmolar nonketotic syndrome

Correct1 Somogyi effect

After a nephrectomy a client arrives in the post-anesthesia care unit in the supine position. Which action should be employed by the nurse to assess the client for signs of hemorrhage? 1 Turn the client to observe the dressings. 2 Press the client's nail beds to assess capillary refill. 3 Observe the client for hemoptysis when suctioning. 4 Monitor the client's blood pressure for a rapid increase

Correct1 Turn the client to observe the dressings.

The nurse concludes that a client with glaucoma needs education when the client states "It is dangerous for me to: 1 Use sedatives." 2 Lift heavy objects." 3 Become constipated." 4 Take atropine in any form."

Correct1 Use sedatives."

When caring for a client, what clinical indicators should the nurse immediately report to the health care provider?(Select all that apply.) 1 Weakness 2 Diaphoresis 3 Tachycardia 4 Cold extremities 5 Flushed skin tone

Correct1 Weakness Correct2 Diaphoresis Correct3 Tachycardia Correct4 Cold extremities

A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery? 1 "Urinary control may be permanently lost to some degree." 2 "An indwelling urinary catheter is required for at least a day." 3 "Your ability to perform sexually will be impaired permanently." 4 "Burning on urination will last while the cystotomy tube is in place."

Correct2 "An indwelling urinary catheter is required for at least a day."

A client with tuberculosis is started on a chemotherapy protocol that includes rifampin (RIF). The nurse evaluates that the teaching about rifampin is effective when the client states: 1 "I need to drink a lot of fluid while I take this medication." 2 "I can expect my urine to turn orange from this medication." 3 "I should have my hearing tested while I take this medication." 4 "I might get a skin rash because it is an expected side effect of this medication."

Correct2 "I can expect my urine to turn orange from this medication

A client with tuberculosis is started on a chemotherapy protocol that includes rifampin (RIF). The nurse evaluates that the teaching about rifampin is effective when the client states: 1 "I need to drink a lot of fluid while I take this medication." 2 "I can expect my urine to turn orange from this medication." 3 "I should have my hearing tested while I take this medication." 4 "I might get a skin rash because it is an expected side effect of this medication."

Correct2 "I can expect my urine to turn orange from this medication."

The nurse is caring for a client four hours after the client's hip replacement surgery. When assisting the client out of bed, the nurse should: 1 Tell the client that both legs must have equal weight bearing 2 Advise the client that the legs must continually be kept wide apart 3 Sit the client in a straight-back chair so that the hips are kept flexed 4 Transfer the client using a mechanical lift because weight bearing on the leg is not allowed

Correct2 Advise the client that the legs must continually be kept wide apart

A client arrives at the emergency department after being bitten by a dog. The bite involved tearing of skin and deep soft tissue injury. The first nursing action is to: 1 Inform the owner of the dog about the client's injury 2 Assess the client's injury, vital signs, and past history 3 Notify the appropriate community agency to capture the dog 4 Obtain a prescription for human rabies immune globulin

Correct2 Assess the client's injury, vital signs, and past history

What should the nurse take into consideration when planning nursing care for a client experiencing an acute episode of rheumatoid arthritis? 1 Inflammation of the synovial membrane rarely occurs. 2 Bony ankylosis of a joint is irreversible and causes immobility. 3 Complete immobility is desired during the acute phase of inflammation. 4 Redness and swelling of a joint signify that irreversible damage has occurred

Correct2 Bony ankylosis of a joint is irreversible and causes immobility.

A client who has just had an adrenalectomy is told about a death in the family and becomes very upset. The nurse notifies the health care provider about the client becoming upset. What is the primary reason the nurse chose to notify the health care provider? 1 With this type of emotion, the dosage of steroids may have to be reduced 2 Despite steroid therapy, the ability to cope with stress will be decreased 3 Mild sedation is needed to assist the client with coping with the loss 4 Feelings of exhaustion with lethargy will occur as a result of stress

Correct2 Despite steroid therapy, the ability to cope with stress will be decreased

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.) 1 Lethargy 2 Headache 3 Diaphoresis 4 Excessive thirst 5 Deep respirations

Correct2 Headache Correct3 Diaphoresis

A pathology report states that a client's urinary calculus is composed of uric acid. Which should the nurse instruct the client to avoid? 1 Milk 2 Liver 3 Cheese 4 Vegetables

Correct2 Liver

A client with Ménière disease is advised to eat a sodium-restricted diet to reduce endolymphatic fluid. Which food selection provides evidence that the nurse's teaching was effective? 1 Cake 2 Macaroni 3 Baked clams 4 Grilled cheese

Correct2 Macaroni

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.) 1 Chvostek sign 2 Muscle cramps 3 Extreme fatigue 4 Cardiac dysrhythmias 5 Increased temperature

Correct2 Muscle cramps Correct3 Extreme fatigue

The health care provider prescribes propylthiouracil (PTU) for a client with the diagnosis of Graves' disease. What should the nurse teach the client when discussing the self-administration of this medication? 1 Increase sources of calcium 2 Observe for signs of infection 3 Take the drug through a straw 4 Wear sunglasses when exposed to sunlight

Correct2 Observe for signs of infection

A nurse is caring for a client who has a radium implant for cancer of the cervix. What is the priority nursing intervention? 1 Store urine in lead-lined containers. 2 Restrict visitors to a 10-minute stay. 3 Wear a lead-lined apron when giving care. 4 Avoid giving injections in the gluteal muscle

Correct2 Restrict visitors to a 10-minute stay

A nurse is providing postoperative care to a client who had a kidney transplant. What assessment is the best indicator of the functioning of the newly transplanted kidney? 1 Renal scan 2 Serum creatinine 3 White blood cell (WBC) count 4 Intake and output balance daily

Correct2 Serum creatinine

A client with multiple sclerosis is informed that this is a chronic, progressive neurological condition. The client asks the nurse, "Will I experience excruciating pain?" What is the nurse's best response? 1 "Tell me about your fears regarding pain." 2 "Analgesics will be prescribed to control the pain." 3 "Pain is not a characteristic symptom of this disease process." 4 "Let's make a list of the things you need to ask your health care provider."

Correct3 "Pain is not a characteristic symptom of this disease process."

A client is taught how to change the dressing and how to care for a recently inserted nephrostomy tube. On the day of discharge the client states, "I hope I can handle all this at home; it's a lot to remember." The best response by the nurse is: 1 "I'm sure you can do it." 2 "Oh, a family member can do it for you." 3 "You seem to be nervous about going home." 4 "Perhaps you can stay in the hospital another day."

Correct3 "You seem to be nervous about going home."

The nurse is providing care to a client who is being treated for bacterial cystitis. Before discharge, it is most important for the client to: 1 Understand the need to drink 4 L of water per day, an essential measure to prevent dehydration 2 Be able to identify dietary restrictions and plan menus 3 Achieve relief of symptoms and to maintain kidney function 4 Recognize signs of bleeding, a complication associated with this type of procedure

Correct3 Achieve relief of symptoms and to maintain kidney function

A client with rheumatoid arthritis calls the outpatient clinic to report that pain with exercising has increased. To decrease pain, the nurse should suggest: 1 For morning stiffness, take a tub bath rather than a hot shower 2 Apply an ice pack directly to the involved joint for no more than 20 minutes at a time 3 Decrease the number of repetitions of the exercises 4 Cease exercising for a day

Correct3 Decrease the number of repetitions of the exercises

A client with type 2 diabetes is admitted for elective surgery. The health care provider prescribes regular insulin even though oral antidiabetics were adequate before the client's hospitalization. The nurse concludes that regular insulin is needed because the: 1 Client will need a higher serum glucose level while on bed rest 2 Possibility of acidosis is greater when a client is on oral hypoglycemics 3 Dosage can be adjusted to changing needs during recovery from surgery 4 Stress of surgery may precipitate uncontrollable periods of hypoglycaemia

Correct3 Dosage can be adjusted to changing needs during recovery from surgery

A client is admitted for the repair and revision of a residual limb after a traumatic amputation of the hand. A week after surgery the client complains of constant throbbing in the affected limb. Which is the most appropriate nursing intervention? 1 Apply cool compresses to the limb 2 Secure a prescription for pain medication 3 Elevate the extremity on two pillows 4 Loosen the bandage around the limb

Correct3 Elevate the extremity on two pillows

Twenty-four hours after a penile implant the client's scrotum is edematous and painful. The nurse should: 1 Assist the client with a sitz bath 2 Apply warm soaks to the scrotum 3 Elevate the scrotum using a soft support 4 Prepare for an incision and drainage procedure

Correct3 Elevate the scrotum using a soft support

A nurse admits a client with a diagnosis of cholelithiasis for surgery. The client asks many questions about the postoperative course after laparoscopic surgery. What is most important for the nurse to include in the teaching plan? 1 Need for long-term dietary restrictions 2 Type of surgical incisions and wound care 3 Explanation of abdominal and scapular pain 4 Encouragement to perform abdominal exercises

Correct3 Explanation of abdominal and scapular pain

An older adult client states, "I walk 2 miles a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated." What should the nurse teach the client? 1 Drink fruit juices if you start to feel dehydrated. 2 Thirst is a good guide to use to determine fluid intake. 3 Fluids should be increased if the urine is getting darker. 4 Water should be consumed when the skin becomes dry

Correct3 Fluids should be increased if the urine is getting darker

An older adult client states, "I walk 2 miles a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated." What should the nurse teach the client? 1 Drink fruit juices if you start to feel dehydrated. 2 Thirst is a good guide to use to determine fluid intake. 3 Fluids should be increased if the urine is getting darker. 4 Water should be consumed when the skin becomes dry

Correct3 Fluids should be increased if the urine is getting darker.

Four hours after surgery the blood glucose level of a client who has type 1 diabetes is elevated. The nurse can expect to: 1 Administer an oral hypoglycemic 2 Institute urine glucose monitoring 3 Give supplemental doses of regular insulin 4 Decrease the rate of the intravenous infusion

Correct3 Give supplemental doses of regular insulin

A jogger sustains multiple fractures of the femur after being hit by a motor vehicle. A nurse responds to the scene of the accident to assist with care. The nurse recalls that, for this type of fracture, immediate life-threatening systemic complications can be minimized by: 1 Elevating the affected limb 2 Encouraging deep breathing and coughing 3 Handling and transporting the client gently 4 Maintaining anatomic alignment of the client's limb

Correct3 Handling and transporting the client gently

A client is admitted to the hospital with a ureteral calculus. The nurse expects what urinary clinical findings? 1 Urgency and mild aching pain 2 Foul odor and dark urine 3 Hematuria with sharp pain when voiding 4 Frequency with small amounts of urine

Correct3 Hematuria with sharp pain when voiding

What does the nurse understand that clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS) share in common? 1 Progressive deterioration until death 2 Deficiencies of essential neurotransmitters 3 Increased risk for respiratory complications 4 Involuntary twitching of small muscle groups

Correct3 Increased risk for respiratory complications

A nurse is caring for a client who sustained trauma to the head. What criteria should a nurse evaluate to determine the client's score on the Glasgow Coma Scale (GCS)? (Select all that apply.) 1 Degree of incontinence 2 Pupillary reaction to light 3 Quality of verbal response 4 Ability to follow commands 5 Stimulus needed to open the eyes

Correct3 Quality of verbal response Correct4 Ability to follow commands Correct5 Stimulus needed to open the eyes

After a basal cell carcinoma is removed by fulguration, a client is given a topical steroid to apply to the surgical site. The nurse evaluates that the teaching regarding steroids and skin lesions is effective when the client states that the primary purpose of the medication is to: 1 Prevent infection of the wound 2 Increase fluid loss from the skin 3 Reduce inflammation at the surgical site 4 Limit itching around the area of the lesion

Correct3 Reduce inflammation at the surgical site

A client is diagnosed with Parkinson disease and receives a prescription for levodopa (L-dopa) therapy. The nurse concludes that the medication is appropriate for this client because it: 1 Blocks the effects of acetylcholine 2 Increases the production of dopamine 3 Restores the dopamine levels in the brain 4 Promotes the production of acetylcholine

Correct3 Restores the dopamine levels in the brain

A client is diagnosed as having invasive cancer of the bladder, and radiation therapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of radiation therapy? 1 Decrease in urine output 2 Increase in physical strength 3 Shrinkage of the tumor on scanning 4 Increase in the quantity of white blood cells (WBCs)

Correct3 Shrinkage of the tumor on scanning

A nurse is caring for a client with the diagnosis of pemphigus vulgaris. Which expected response does the nurse need to address in the client's plan of care? 1 Paralysis 2 Infertility 3 Skin lesions 4 Impaired digestion

Correct3 Skin lesions

When changing a postoperative client's dressing, the nurse is careful not to introduce microorganisms into the incision. What type of asepsis includes this principle? 1 Wound asepsis 2 Medical asepsis 3 Surgical asepsis 4 Concurrent asepsis

Correct3 Surgical asepsis

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.) Incorrect1 Pruritus 2 Oliguria 3 Tachycardia 4 Cloudy outflow 5 Abdominal pain

Correct3 Tachycardia Correct4 Cloudy outflow Correct5 Abdominal pain

A client who has repeated episodes of cystitis is scheduled for a cystoscopy to determine the possibility of urinary tract abnormalities. The client asks the nurse to describe the procedure. The nurse's most appropriate response is, "This procedure is: 1 A computerized scan that outlines the bladder and surrounding tissue." 2 An x-ray film of the abdomen, kidneys, ureters, and bladder after administration of dye." 3 The visualization of the inside of the bladder with an instrument connected to a source of light." 4 The visualization of the urinary tract through ureteral catheterization and the use of radiopaque material."

Correct3 The visualization of the inside of the bladder with an instrument connected to a source of light

A client who has repeated episodes of cystitis is scheduled for a cystoscopy to determine the possibility of urinary tract abnormalities. The client asks the nurse to describe the procedure. The nurse's most appropriate response is, "This procedure is: 1 A computerized scan that outlines the bladder and surrounding tissue." 2 An x-ray film of the abdomen, kidneys, ureters, and bladder after administration of dye." 3 The visualization of the inside of the bladder with an instrument connected to a source of light." 4 The visualization of the urinary tract through ureteral catheterization and the use of radiopaque material."

Correct3 The visualization of the inside of the bladder with an instrument connected to a source of light."

A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. This is necessary because: 1 Reflexes have been lost. 2 There is partial transection of the cord. 3 There is damage above the sixth thoracic vertebra. 4 Flaccid paralysis of the lower extremities has occurred.

Correct3 There is damage above the sixth thoracic vertebra.

The nurse provides education to a client about the side effects of furosemide (Lasix). Which client statements indicate that the teaching is understood? (Select all that apply.) 1 "I must not eat citrus fruits." 2 "I should wear dark glasses." 3 "I should avoid lying flat in bed." 4 "I should change my position slowly." 5 "I must eat a food that contains potassium every day."

Correct4 "I should change my position slowly." Correct5 "I must eat a food that contains potassium every day."

Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. The mostappropriate response by the nurse is: 1 "You will have an abdominal incision and a dressing." 2 "Your urine will be pink and free of clots." 3 "There will be an incision between your scrotum and rectum." 4 "There will be an indwelling urinary catheter and a continuous bladder irrigation in place."

Correct4 "There will be an indwelling urinary catheter and a continuous bladder irrigation in place."

An older client is brought to the hospital by a family member because of deep partial-thickness burns on the arms and hands. The client protests being hospitalized and asks, "Why can't I just go home and have my spouse care for me?" What is the best response by the nurse? 1 "You sound upset, but your health care provider knows best. You should do what is prescribed." 2 "Your spouse is very capable, but if your burns get infected, a family member can't give you the injections you will need." 3 "Your burns are more serious than you think, and we have specially trained people here just to take care of you." 4 "You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital.

Correct4 "You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital

A nurse is caring for an alert client who has diabetes and is receiving an 1800-calorie American Diabetic Association diet. The client's blood glucose level is 60 mg/dL. The health care provider's protocol calls for treatment of hypoglycemia with 15 g of a simple carbohydrate. The nurse should: 1 Provide 12 ounces of non-diet soda 2 Give 25 mL dextrose 50% by slow intravenous (IV) push 3 Have the client drink 8 ounces of fruit juice 4 Ask the client to ingest one tube of glucose gel

Correct4 Ask the client to ingest one tube of glucose gel

A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons? 1 Absent reflexes 2 Flaccid muscles 3 Trousseau sign 4 Babinski response

Correct4 Babinski response

The nurse is teaching first aid to a group of community members. A participant asks what first aid should be administered to a person that suffers extensive burns. An appropriate response by the nurse is to call 911 and: 1 Apply ice to burned areas; the intervention will decrease pain 2 Use first aid cream to burned areas 3 Do nothing; attempting to treat the burned areas may cause further damage 4 Cover the burned areas with a bed sheet

Correct4 Cover the burned areas with a bed sheet

Which clinical manifestation should a nurse expect a client with diabetes insipidus to exhibit? 1 Increased blood glucose 2 Decreased serum sodium 3 Increased specific gravity 4 Decreased urine osmolarity

Correct4 Decreased urine osmolarity

A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. For what physiological response to the radiation should the nurse assess the client during the return visit to the radiology department? 1 Ataxia 2 Hypoxia 3 Arthralgia 4 Dysphagia

Correct4 Dysphagia

Which assessment finding supports the nurse's conclusion that a prosthesis for a client with an above-the-knee amputation fits correctly? 1 Skin that is cool to the touch 2 Shrinking of the residual limb 3 Absence of phantom limb pain 4 Evenly darkened skin of the residual limb

Correct4 Evenly darkened skin of the residual limb

A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What should the nurse expect to identify when assessing this client? 1 Weight loss 2 Hypoglycemia 3 Decreased blood pressure 4 Inadequate wound healing

Correct4 Inadequate wound healing

A client has a shoulder immobilizer after surgical repair of a fractured humerus. What should be included in the nurse's instruction to the client about the appropriate use of the immobilizer? 1 Place the elbow on a pillow when sitting in a chair. 2 Adjust the upper arm and wristbands so they are slack. 3 Loosen the chest band to exercise the shoulder periodically. 4 Release the wristband to exercise the forearm and hand routinely

Correct4 Release the wristband to exercise the forearm and hand routinely

A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). The plan should include the importance of: 1 Trimming toenails so that they are short and rounded 2 Checking bathwater temperature by putting the toes in first 3 Using alcohol to rub hands, feet, legs, and arms at least two times a day 4 Securing professional treatment for any minor injuries to the extremities

Correct4 Securing professional treatment for any minor injuries to the extremities

A male client has discharge from his penis. Gonorrhea is suspected. To obtain a specimen for a culture, the nurse should: 1 Instruct the client to provide a semen specimen 2 Swab the discharge when it appears on the prepuce 3 Teach the client how to obtain a clean catch specimen of urine 4 Swab the drainage directly from the urethra to obtain a specimen

Correct4 Swab the drainage directly from the urethra to obtain a specimen

A client is scheduled for an intravenous pyelogram (IVP). The nurse explains that on the day before the IVP the client must: 1 Avoid fats and proteins 2 Drink a large amount of fluids 3 Omit dinner and limit beverages 4 Take a laxative before going to bed

Correct4 Take a laxative before going to bed

A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is diagnosed and an anticholinergic medication is prescribed. The nurse is planning care with the client and spouse. What instruction is the priority? 1 Eat foods that are pureed 2 Perform range-of-motion exercises 3 Recommend taking a stool softener daily 4 Take the medication according to a specific schedule

Correct4 Take the medication according to a specific schedule

A client with a left ureteral calculus is scheduled for a transurethral ureterolithotomy. During the preoperative assessment, the nurse expects the client to report pain: 1 That is a boring-type pain that is located in the left flank 2 That occurs with each urination and is located at the level of the kidneys 3 That is dull and constant and located in the costovertebral angle 4 That is spasmodic and located in the left side and radiating to the suprapubic area

Correct4 That is spasmodic and located in the left side and radiating to the suprapubic area

A client had a colostomy surgery and is learning how to care for the skin around the stoma. What should the nurse include in the teaching plan for this client? 1 Avoid the use of soap and other irritating agents 2 Rinse with hydrogen peroxide and apply a gauze pad 3 Pour saline over the stoma and firmly wipe away the fecal matter 4 Wash the area gently with soap and water before applying an appliance

Correct4 Wash the area gently with soap and water before applying an appliance

Two portable drainage catheters with hemovacs attached were placed during a client's hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed, the nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters. The priority nursing intervention is to: 1 Turn the client onto the right side 2 Notify the health care provider immediately 3 Document the output as an expected finding 4 Irrigate the drainage catheter to ensure patency

Correct2 Notify the health care provider immediately

A nurse is caring for a male client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? (Select all that apply.) 1 Polyuria 2 Obese trunk 3 Hypotension 4 Sleep disturbance 5 Thin arms and legs

Correct2 Obese trunk Correct4 Sleep disturbance Correct5 Thin arms and legs

A client follows a vegetarian diet and must compensate for the lack of vitamin B12 found in food of animal origin. Which food should the nurse encourage the client to consume each day? 1 One orange 2 One glass of soy milk 3 Two handfuls of nuts 4 Two servings of green vegetables

Correct2 One glass of soy milk

What should a nurse teach the client to do to avoid lipodystrophy when self-administering insulin therapy? 1 Exercise regularly. 2 Rotate injection sites. 3 Use the Z-track technique. 4 Avoid massaging the injection site

Correct2 Rotate injection sites.

A health care provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. Two months after being started on the antithyroid medication, the client calls the nurse and complains of feeling tired and looking pale. What should the nurse do? 1 Advise the client to get more rest. 2 Schedule the client for an appointment. 3 Instruct the client to skip one dose daily. 4 Tell the client to increase the medication.

Correct2 Schedule the client for an appointment

What nursing action will limit hypoxia when suctioning a client's airway? 1 Apply suction only after catheter is inserted. 2 Limit suctioning with catheter to half a minute. 3 Lubricate the catheter with saline before insertion. 4 Use a sterile suction catheter for each suctioning episode

1 Apply suction only after catheter is inserted.

The primary responsibility of a nurse when caring for a client with a chest tube attached to a three-chamber underwater-seal drainage system is to: 1 Ensure maintenance of the closed system 2 Maintain mechanical suction to the system 3 Encourage the client to deep breathe and cough 4 Keep the client in the dorsal recumbent position

1 Ensure maintenance of the closed system

A nurse is teaching Hands Only Basic Life Support for adults in the community. What should the rescuer do first after determining that the person is not responding and the emergency medical system has been activated? 1 Identify the absence of pulse. 2 Give two rescue breaths with a CPR mask. 3 Perform the head tilt-chin lift maneuver. 4 Perform chest compression at a rate of 100/min

1 Identify the absence of pulse.

After sustaining multiple internal injuries when hit by a motor vehicle, a client has a sudden drop in blood pressure to 80/60 mm Hg. What does the nurse determine probably caused this response? 1 Reduction in circulating blood volume. 2 Diminished vasomotor stimulation to arterial walls. 3 Vasodilation resulting from diminished vasoconstrictor tone. 4 Cardiac decompensation resulting from electrolyte imbalance.

1 Reduction in circulating blood volume

A client is discharged with a prescription for sustained-release nitroglycerin. What should the nurse teach the client about sustained-release nitroglycerin? 1 Swallow the capsule whole 2 Take milk with the medication 3 Hold the tablet under the tongue 4 Note a stinging feeling when the drug is under the tongue

1 Swallow the capsule whole

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.) 1 Vomiting relieves pain. 2 Eating food prevents pain. 3 Pain described as gnawing. 4 Flatulence accompanies pain. 5 Pain occurs a half hour after meals

1 Vomiting relieves pain. 3 Pain described as gnawing. 5 Pain occurs a half hour after meals

Potassium supplements are prescribed for a client receiving diuretic therapy. What client statement indicates that the teaching about potassium supplements is understood? 1 "I will report any abdominal distress." 2 "I should use salt substitutes with my food." 3 "The drug must be taken on an empty stomach." 4 "The dosage is correct if my urine output increases."

1. "I will report any abdominal distress."

A client is hospitalized with chest pain. The client's spouse voices concern about how pale the client is. What is the best response by the nurse? 1 "You must be frightened by this." 2 "Paleness is expected with heart problems." 3 "Other people get pale and recover without any complications." 4 "I can understand why you are worried, but your spouse will be all right."

1. "You must be frightened by this."

The nurse evaluates that the preoperative teaching regarding a bronchoscopy was understood when the client states, "I recognize I cannot eat or drink for several hours after the procedure to prevent: 1 Gastric irritation." 2 Aspiration of food." 3 Projectile vomiting." 4 Abdominal distention.

2 Aspiration of food."

A client with extensive bone and soft tissue injuries to the right leg is on bed rest. When positioning the client, the nurse should: 1 Keep the right leg resting straight on the bed, parallel to the left leg 2 Elevate the entire right leg with pillows, keeping the foot higher than the knee 3 Maintain both legs on the bed and use an abduction pillow to keep them separated 4 Attach a padded ankle sling to a Balkan frame to support the right foot and elevate the leg

2 Elevate the entire right leg with pillows, keeping the foot higher than the knee

A male client who is receiving prolonged steroid therapy complains of always being thirsty and urinating frequently. What is the nurse's best initial action? 1 Have the client assessed for an enlarged prostate. 2 Obtain a urine specimen from the client to test for ketonuria. 3 Perform a finger stick to test the client's blood glucose level. 4 Assess the client's lower extremities for the presence of pitting edema

3 Perform a finger stick to test the client's blood glucose level.

What should a nurse do to decrease or control the sensory and cognitive disturbances that can occur after a client has open-heart surgery? 1 Restrict family visits 2 Withhold analgesic medications 3 Plan for maximum periods of rest 4 Keep the room light on most of the time

3 Plan for maximum periods of rest

A nurse is caring for a client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

3 Respiratory acidosis

A client is admitted to the hospital with a diagnosis of cancer of the larynx, and a total laryngectomy is scheduled. Which nursing action is most important in the immediate postoperative management of this client? 1 Instructing the client to whisper 2 Placing the client in the orthopneic position 3 Suctioning the tracheostomy tube whenever necessary 4 Changing the outer tracheostomy tube at least once a day

3 Suctioning the tracheostomy tube whenever necessary

What client response indicates to the nurse that a vasodilator medication is effective? 1 Pulse rate decreases from 110 to 75 2 Absence of adventitious breath sounds 3 Increase in the daily amount of urine produced 4 Blood pressure changes from 154/90 to 126/72

4 Blood pressure changes from 154/90 to 126/72

The nurse provides discharge teaching to a client with tuberculosis and reinforces that the treatment measure with thehighest priority is: 1 Getting sufficient rest 2 Getting plenty of fresh air 3 Changing the current lifestyle 4 Consistently taking prescribed medication

4 Consistently taking prescribed medication

What breathing exercises should the nurse teach a client with the diagnosis of emphysema? 1 An inhalation that is prolonged to promote gas exchange. 2 Abdominal exercises to limit the use of accessory muscles. 3 Sit-ups to help strengthen the accessory muscles of respiration. 4 Diaphragmatic exercises to improve contraction of the diaphragm

4 Diaphragmatic exercises to improve contraction of the diaphragm

The nurse reinforces instructions about how to use a nebulizer to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that additional teaching is needed when the client: 1 Places the tip of the mouthpiece an inch beyond the lips 2 Holds the inspired breath for at least three seconds 3 Exhales slowly through the mouth with lips pursed slightly 4 Inhales with the lips tightly sealed around the mouthpiece of the nebulizer

4 Inhales with the lips tightly sealed around the mouthpiece of the nebulizer

A nurse is assessing two clients. One client has ulcerative colitis and the other client has Crohn's disease. Which is more likely to be identified in the client with ulcerative colitis than the client with Crohn's disease? 1 Inclusion of transmural involvement of the small bowel wall 2 Correlation with increased malignancy because of malabsorption syndrome 3 Pathology beginning proximally with intermittent plaques found along the colon 4 Involvement starting distally with rectal bleeding that spreads continuously up the colon

4 Involvement starting distally with rectal bleeding that spreads continuously up the colon

Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? 1 Face tent 2 Venturi mask 3 Nasal cannula 4 Nonrebreather mask

4 Nonrebreather mask

A nurse is caring for a client who had emergency surgery for a ruptured appendix. What action should the nurse take when the client manifests signs and symptoms of shock? 1 Prepare for a blood transfusion 2 Elevate the head of the bed 30 degrees 3 Administer 2 L oxygen via nasal cannula 4 Notify the health care provider immediately

4 Notify the health care provider immediately

Which medications are associated commonly with upper gastrointestinal (GI) bleeding? (Select all that apply.) Correct1 Acetylsalicylic acid (Aspirin) Correct2 Methylprednisolone (Solu-Medrol) 3 Acetaminophen (Tylenol) Correct4 Ibuprofen (Advil) 5 Ciprofloxacin (Cipro)

Acetylsalicylic acid (Aspirin) Ibuprofen (Advil)

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.) 1 Raw carrots 2 Boiled spinach 3 Sweet potatoes 4 Brussels sprouts 5 Asparagus spears

Boiled spinach Sweet potatoes

A client is admitted with anorexia, weight loss, abdominal distention, and abnormal stools. A diagnosis of malabsorption syndrome is made. What nursing action should the nurse implement to best meet this client's needs? 1 Allow the client to eat food preferences. 2 Encourage the consumption of high-protein foods. 3 Institute intravenous (IV) therapy to improve the client's hydration. 4 Maintain nothing by mouth status because food precipitates diarrhea

Correct2 Encourage the consumption of high-protein foods.

A client with history of multiple chronic illnesses comes to the emergency department (ED) complaining of a small progressive weight loss over the last month and feeling lethargic and thirsty all the time. The client's fasting blood glucose is 180 mg/dL and vital signs are blood pressure (BP) 118/78 mm Hg, oral temperature 99.6º F, pulse 72 beats per minute and regular, and respirations 22 breaths per minute and irregular. The nurse reviews the assessment findings and the client's medical record. What condition does the nurse conclude the client is experiencing? 1 Hypervolemia 2 Hyperglycemia 3 Infectious process 4 Respiratory distress

Correct2 Hyperglycemia

After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first? 1 Elevate the legs and tell the client to drink more fluids. 2 Instruct the client to remain in bed and notify the health care provider. 3 Rub the client's legs to stimulate circulation and cover the client with a blanket. 4 Tell the client about the dangers of prolonged bed rest and encourage ambulation

Correct2 Instruct the client to remain in bed and notify the health care provider.

Which instructions should the nurse include in the teaching plan for a client with hyperlipidemia who is being discharged with a prescription for cholestyramine (Questran)? 1 "Increase your intake of fiber and fluid." 2 "Take the medication before you go to bed." 3 "Check your pulse before taking the medication." 4 "Contact your health care provider if your skin or sclera turn yellow."

Correct1 "Increase your intake of fiber and fluid."

A client with cancer of the lung says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse conclude the client is in? 1 Bargaining 2 Frustration 3 Depression 4 Rationalization

Correct1 Bargaining

A financially struggling, large family is instructed by the home health nurse about ways to increase the dietary intake of calcium. Which suggestion should the nurse make? 1 Collards or kale in one meal a day 2 Fruit-flavored yogurt every other day 3 Eight ounces of milk with every meal 4 Bread made with cornmeal each morning

Correct1 Collards or kale in one meal a day

Which factors should the nurse identify that can precipitate hyponatremia? (Select all that apply.) 1 Gastrointestinal (GI) suction 2 Diuretic therapy 3 Inadequate antidiuretic hormone (ADH) secretion 4 Continuous bladder irrigation 5 Parenteral infusion of 0.9% sodium chloride

Correct1 Gastrointestinal (GI) suction Correct2 Diuretic therapy Correct4 Continuous bladder irrigation

A nurse is assessing a client with Cushing syndrome. Which signs should the nurse expect the client to exhibit? (Select all that apply.) 1 Hirsutism 2 Round face 3 Pitting edema 4 Buffalo hump 5 Hypoglycemia

Correct1 Hirsutism Correct2 Round face Correct4 Buffalo hump

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.) 1 Iced tea 2 Red meat 3 Club soda 4 Hot cocoa 5 Chocolate pudding

Correct1 Iced tea Correct4 Hot cocoa Correct5 Chocolate pudding

A client with type 1 diabetes is transported via ambulance to the emergency department of the hospital. The client has dry, hot, flushed skin and a fruity odor to the breath and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing? 1 Ketoacidosis 2 Somogyi phenomenon 3 Hypoglycemic reaction 4 Hyperosmolar nonketotic coma

Correct1 Ketoacidosis

The nurse provides teaching about self-care management to a client who recently was diagnosed with emphysema. The nurse concludes that further teaching is needed when the client states: 1 "I will try to avoid smoking." 2 "I will maintain complete bed rest." 3 "I'll control the temperature in my home." 4 "I'll need to clean my mouth several times a day"

Correct2 "I will maintain complete bed rest."

Which statement made by a client after attending a class on nutrition indicates an understanding of the importance of essential amino acids? 1 "Amino acids can be made by the body because they are essential to life." 2 "They come from the diet because they cannot be synthesized in the body." 3 "They are used in key processes essential for growth once they are synthesized by the body." 4 "Essential amino acids are required for metabolism, whereas the other amino acids are not."

Correct2 "They come from the diet because they cannot be synthesized in the body."

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.) 1 Irritability 2 Dysrhythmias 3 Muscle weakness 4 Abdominal cramps 5 Tingling of the fingertips

Correct2 Dysrhythmias Correct3 Muscle weakness

A client has a new colostomy. The nurse has provided teaching related to when the client should irrigate the colostomy. Which client statement indicates correct understanding of the teaching? 1 "After it gets done healing in a few weeks, I will begin irrigating it just before going to bed each day." 2 "It will need to be irrigated each morning before I can eat any food." 3 "I plan to irrigate it in the late morning, the same time I had a bowel movement every day before I had my surgery." 4 "I can wait to start irrigating it until after I have gotten used to this bag and change in lifestyle."

Correct3 "I plan to irrigate it in the late morning, the same time I had a bowel movement every day before I had my surgery."

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.) 1 Add milk to coffee. 2 Elevate the foot of the bed. 3 Avoid caffeine-containing products. 4 Eat three evenly spaced meals daily. 5 Chew thoroughly while eating slowly

Correct3 Avoid caffeine-containing products Chew thoroughly while eating slowly

After an acute episode of gastrointestinal (GI) bleeding, a client is diagnosed with gastric ulcer. The client receives a prescription for ranitidine (Zantac) 150 mg twice a day to be taken with meals. The nurse contacts the health care provider about the prescription because ranitidine: 1 Should be given on an empty stomach 2 Is contraindicated for gastric ulcers 3 Can be administered by a variety of routes 4 Is recommended to be given at a higher dose

Correct3 Can be administered by a variety of routes

While receiving a blood transfusion, a client develops flank pain, chills, fever, and hematuria. What type of transfusion reaction does the nurse conclude that the client probably is experiencing? 1 Allergic 2 Pyrogenic 3 Hemolytic 4 Anaphylactic

Correct3 Hemolytic

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. What is thepriority nursing intervention? 1 Initiate oxygen therapy 2 Obtain a chest x-ray film immediately 3 Place client in a high-Fowler position 4 Assess the client for a pleural friction rub

Correct3 Place client in a high-Fowler position

When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs and symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider? 1 Substernal chest pain 2 Episodes of palpitation 3 Severe shortness of breath 4 Dizziness when standing up

Correct3 Severe shortness of breath

The nurse is making rounds on a patient 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.) 1 Monitor for signs of alopecia. 2 Encourage an increase in fluids. 3 Wash hands before entering the client's room. 4 Advise use of a soft toothbrush for oral hygiene. 5 Report an elevation in temperature immediately. 6 Encourage the client to eat raw, fresh fruits and vegetables

Correct3 Wash hands before entering the client's room. Correct4 Advise use of a soft toothbrush for oral hygiene. Correct5 Report an elevation in temperature immediately.

A client is scheduled for a bilateral adrenalectomy. Before surgery, steroids are administered to the client. What does the nurse determine is the reason for the steroids? 1 Foster accumulation of glycogen in the liver 2 Increase the inflammatory action to promote scar formation 3 Facilitate urinary excretion of salt and water following surgery 4 Compensate for sudden lack of these hormones following surgery

Correct4 Compensate for sudden lack of these hormones following surgery

Which significant risk factors for coronary heart disease carry a greater risk for women than for men? (Select all that apply.) 1 Obesity 2 Smoking 3 Hypertension 4 Diabetes mellitus 5 Low levels of high-density lipoprotein (HDL) cholesterol

Correct4 Diabetes mellitus Correct5 Low levels of high-density lipoprotein (HDL) cholesterol

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.) 1 Mental confusion 2 Increased cholesterol 3 Brown-colored stools 4 Flapping hand tremors 5 Hyperactive deep tendon reflexes

Correct4 Flapping hand tremors Mental confusion

A client is being discharged after an acute episode of hepatitis. The nurse expects the primary health care provider to prescribe which type of diet for this client? 1 Low calorie, high protein, low carbohydrate, low fat 2 High calorie, low protein, high carbohydrate, high fat 3 Low calorie, low protein, low carbohydrate, moderate fat 4 High calorie, high protein, high carbohydrate, moderate fat

Correct4 High calorie, high protein, high carbohydrate, moderate fat

A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a common early sign of laryngeal cancer for which the nurse should assess this client? 1 Aphasia 2 Dyspnea 3 Dysphagia 4 Hoarseness

Correct4 Hoarseness

At 4:30 PM, a client who is receiving human insulin (Humulin N) every morning states, "I feel very nervous." The nurse observes that the client's skin is moist and cool. What is the nurse's most accurate interpretation of what the client is likely experiencing? 1 Polydipsia 2 Ketoacidosis 3 Glycogenesis 4 Hypoglycemia

Correct4 Hypoglycemia

A health care provider prescribes daily docusate sodium (Colace) for a client. The nurse determines that the action of this drug in the gastrointestinal (GI) tract is to: 1 Lubricate the feces 2 Create an osmotic effect 3 Stimulate motor activity 4 Lower the surface tension of feces

Correct4 Lower the surface tension of feces

A client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is: 1 Pneumonia 2 Hemorrhage 3 Wound infection 4 Pulmonary embolism

Correct4 Pulmonary embolism

A client with emphysema has a history of smoking two packs of cigarettes a day. What is the best approach for the nurse to help the client stop smoking? 1 Teach pursed-lip breathing 2 Encourage the client to reduce emotional stress 3 Obtain a referral to a smoking cessation program in the community 4 Suggest that the client limit smoking to one pack of cigarettes a day

Correct4 Suggest that the client limit smoking to one pack of cigarettes a day

A client had thoracic surgery. The nurse should monitor for what clinical manifestations that may indicate acute pulmonary edema? Select all that apply. 1 Crackles 2 Cyanosis 3 Dyspnea 4 Bradypnea 5 Frothy sputum

Crackles Cyanosis Dyspnea Frothy sputum

A nurse is caring for a client in respiratory distress. The health care provider prescribes oxygen via a non-rebreather mask. Which mask should the nurse use to implement the oxygen prescription?

d