Med surg Practice predictor A 2020

a nurse is caring for a client who reports stomatitis, which of the following dietary recommendations should the nurse make?

eat soft foods r- The nurse should instruct a client who has stomatitis to eat soft, nonirritating foods to decrease irritation to the oral mucosa.

a nurse is caring for a client who has difficulty swallowing. which of the following actions should the nurse implement to prevent aspiration?

give the client liquids with increased viscosity. r-Thickened liquids are easier for the client to swallow and can prevent aspiration.

a nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching?

apply cold packs to the inflamed joints. R-The nurse should instruct the client to use both warm and cold packs on inflamed joints to decrease pain.

a nurse is collecting data from a client who has hypothyroidism. which of the following manifestation should the nurse anticipate?

bradycardia r- The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused by a decrease in the client's metabolic rate.

a nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. which of the following statement should the nurse make?

"Avoid bending your hips more than 90 degrees." The nurse should instruct the client to avoid bending their hips more than 90° to prevent dislocation of the replacement hip.

a nurse is reinforcing teaching a client who has asthma, which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? a. "I should expect to feel sleepy after using my albuterol inhaler." b. "I never forget to rinse my mouth after using my budesonide inhaler." c. "Between office visits, I keep a record of how many times I use my albuterol inhaler." d. "I use my albuterol inhaler before I go swimming." e. "I should use my budesonide inhaler before using my albuterol inhaler."

"Between office visits, I keep a record of how many times I use my albuterol inhaler" is correct. The client should record the number of times that they use their albuterol inhaler. This information can assist the provider to determine the effectiveness of the medication. "I never forget to rinse my mouth after using my budesonide inhaler" is correct. The client should rinse their mouth after using a budesonide inhaler to reduce the risk for oral fungal infection. "I use my albuterol inhaler before I go swimming" is correct. The client should use the albuterol inhaler before exercise to prevent exercise-induced bronchospasms.

a home health nurse is reinforcing teaching about preventing asthma attacks with a client who has asthma. which of the following instructions should the nurse include in the teaching? a. "Cover the floor of your bedroom with carpet." b. "Do not allow visitors to smoke cigarettes in your home." c. "Breathe cold air to ease feelings of shortness of breath." d. "Open the windows in your home during the spring to increase air flow."

"Do not allow visitors to smoke cigarettes in your home."

a home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. which of the following statements indicates that the client is adhering to the nurses instruction? a. "I apply rubbing alcohol to my feet every day to prevent infection." b. "I will wear clean, knee-high wool socks every day to help improve my circulation." c. "I use hot water bottles to keep my feet warm at night." d. "I don't cross my legs anymore."

"I don't cross my legs anymore." r-clients who have peripheral vascular disease should not cross their legs because it can impede circulation.

a nurse is reinforcing teaching a client who has mitral valve disease. which of the following statements by the client indicates an understanding of the disease process?

"I should call my doctor if my ankles swell." R-Swelling of the ankles can indicate heart failure. The client should report this finding to the provider.

a nurse is reinforcing teaching about gastroesophageal reflux disease with a client, which of the following statements by the cliet indicates an understanding of the teaching?

"I should wait at least 2 hours after eating before going to bed." The client should wait to lie down or go to bed at least 2 hr after eating to minimize reflux.

a nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. which of the following statements by the client demonstrates an understanding of the teaching? a. i will perform the exam before i shower b. i will check my testicles every 6 mos c. i undertand that testicular csncer is typecally painless d i understand that pea sized lumps are normal

"I understand that testicular cancer is typically painless." r-Clients should report a lump that is not painful because testicular cancer is typically painless.

a nurse is reinforcing teaching about glycosylated hemoglobin (hba1c) testing with a client who has diabetes mellitus, which of the following statements indicates that the client understands the teaching?

"I will have my HbA1c checked twice per year." r-An HbA1c test provides the client's average glucose level for the preceding 3 months. The nurse should instruct the client to have their HbA1c tested twice yearly to manage their glucose.

a nurse is reinforcing teaching with a client who has systemic lupus erythematosus (sle) and is to begin taking methylprednisolone orally, which of the following statements should the nurse include in the teaching?

"Limit contact with large groups of people." r-Glucocorticoids cause immunosuppression and can mask infection. The client should limit contact with sources of possible infections, such as large groups of people.

a nurse is reinforcing teaching with a client who is taking insulin glargine. which of the following info should the nurse include in the teaching? A. "this type of insulin should be given at the same time every day." b "This insulin can be mixed with short-acting insulin in a single syringe." c "This type of insulin can be used in a pump." d "This insulin has an increased risk for hypoglycemia."

"This type of insulin should be given at the same time every day." MY ANSWER Insulin glargine is released in the body over a 24-hr period. The nurse should instruct the client to administer the insulin at the same time each day to maintain consistent serum levels for optimal therapeutic effect.

a nurse is reinforcing teaching with a client who is to begin using an insulin pump. which of the following instructions should the nurse include? a. "Insert the infusion needle into intramuscular tissue." b. "Change the needle every 5 days." c. "Calculate the insulin for each meal by using an insulin-to-protein ratio." d. "Use rapid-acting insulin in the infusion device."

"Use rapid-acting insulin in the infusion device." r-The nurse should instruct the client to use rapid-acting insulin with an insulin pump.

a nurse is reinforcing teaching with a client who has gonorrhea. which of the following info should the nurse include?

"You are at risk for infertility with this infection, regardless of treatment." r-The nurse should inform the client that there is a risk for infertility as a result of this infection.

a nurse is caring for a client who has terminal pancreatic cancer. the client states, "i don't think i can go any longer" which of the following responses should the nurse make?

"You feel like you want to discontinue treatment?" r-The nurse is clarifying and acknowledging the client's feelings by establishing a trusting relationship. This question encourages the client to expand on their feelings.

a nurse is discussing health screening guidelines with an older adult client. which of the following statements should the nurse include?

"You should have a pneumococcal immunization every 10 years." r-The nurse should remind the client to have a pneumococcal immunization at age 65 and every 10 years thereafter to protect them from acquiring pneumonia.

a nurse is monitoring a client who is taking acarbose. which of the following findings should the nurse identify as an adverse effect of the meds? a. Polyuria b. Abdominal cramps c. Renal insufficiency d. Insomnia

Abdominal cramps r-Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this medication.

a nurse is contributing to the plan of care for a client who has menieres disease, which of the following interventions should the nurse include in the plan of care?

Administer an antiemetic to the client. r-The nurse should plan to administer an antiemetic to a client who has Ménière's disease to reduce the duration and severity of the attack.

a nurse is caring for a client and administers penicillin im. the client begins exhibiting hives and has severe difficulty breathing. after establishing a patent airway, which of the following actions should the nurse take next?

Administer epinephrine. The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema.

a nurse is caring for a client who had an acute ischemic stroke 1 day ago. which of the following actions should the nurse take to reduce the risk of aspiration?

Allow for 30 min of rest before meals. r-The nurse should allow the client to rest for 30 min before meals to prevent aspiration.

a nurse is planning to implement droplet precaution for a client who has manifestation of pertussis, which of the following interventions should the nurse include when contributing to the plan of care? a. Apply a mask on the client if transport is needed. b. Wear a mask when working within 1.2 m (4 feet) of the client. c. Don a gown when visiting with the client. d. Wear an N95 mask when entering the client's room.

Apply a mask on the client if transport is needed. r-The nurse should apply a mask to a client who has manifestations of pertussis during transport to prevent exposure to others.

a nurse is reinforcing teaching a client who scheduled for a guaiac fecal occult blood test. which of the following instructions should the nurse include the teaching? a. Do not eat or drink for 6 hr prior to the test. b. Ensure that the stool specimen is obtained in the morning. c. Take ibuprofen for mild pain until the test is complete. d. Avoid eating red meat for 3 days prior to the test.

Avoid eating red meat for 3 days prior to the test. r- The nurse should instruct the client to avoid eating red meat for 3 days prior to the guaiac fecal occult blood test because this can lead to a false positive result.

a nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen, which of the following instructions should the nurse include in the teaching.

Avoid stopping this medication suddenly. r-The nurse should instruct the client to avoid stopping baclofen suddenly because it can result in adverse reactions, including seizures, paranoia, and hallucinations.

a nurse is preparing to admin scheduled meds to a client. which of the following prescriptions should the nurse verify with the provider?

Ceftriaxone r-Clients who have a severe sensitivity to penicillin can have a cross-sensitivity reaction to ceftriaxone, a cephalosporin. Therefore, the nurse should contact the provider to clarify the prescription.

a nurse is renforcing teaching with the caregiver of a client who has a cervical injury and has a halo vest in place. which of the following safety precautions should the nurse include in the teaching?

Change the sheepskin liner weekly. r-The nurse should provide instruction regarding the care and maintenance of the vest. The instruction should include changing the sheepskin liner either when soiled or at least once per week to prevent skin irritation.

a nurse is assisting with the care of a client who is receiving .9% sodium chloride by continuous IV infusion, client reports swelling at the IV site. in which order should the nurse perform the following steps?

Check the IV site is the first step. The first action the nurse should take when using the nursing process is to check the IV site for infiltration.Stop the infusion is the second step. If infiltration is found, the next step the nurse should take is to stop the infusion to prevent vein and tissue damage. Withdraw the IV catheter is the third step. Once the infusion is stopped, the nurse should remove the IV catheter. Elevate the affected arm is the fourth step. The nurse should elevate the affected extremity to decrease swelling. Notify the charge nurse is the fifth step. The nurse should notify the charge nurse about the client's condition.

a nurse is assisting with the care of a client who has a newly-inserted water-seal closed chest tube. which of the following findings should the nurse report to the provider?

Chest drainage is greater than 70 mL/hr. r- The nurse should identify that chest drainage of greater the 70 mL/hr can indicate a complication and should be reported to the provider.

a nurse is caring for a client who has a hx of breast cancer, the client asks the nurse about birth control, which of the following methods of birth control is a contraindication for this client?

Combination oral contraceptives r- the nurse should identify that combination oral contraceptives are contraindicated for this client because they increase estrogen levels, which can stimulate the growth of any remaining cancerous breast cells.

a nurse is reviewing the lab results of a client who is scheduled for a CT scan with an IV contrast agent, which of the following lab finding should the nurse report to the provider prior to the procedure?

Creatinine 1.9 mg/dL r-Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should report the finding to the provider before the client has a CT scan with an IV contrast agent. This finding places the client at risk for developing contrast-induced nephropathy.

a nurse is contributing to the plan of care for a client who has peripheral arterial disease of the lower extremities, which of the following interventions should the nurse include? a. Apply support stockings before getting out of bed. b dangle the extremities off the side of the bed. c. perform manual massage of the affected extremities. d Place moist heat pads on the extremities

Dangle the extremities off the side of the bed. r-The nurse should include in the plan of care to have the client dangle their lower extremities off the side of the bed to aid in reducing pain by increasing arterial blood flow. The client should not raise the lower extremities above the level of the heart when resting in bed because it impairs arterial blood flow. avoid applying stocking bc it interferes w/ the arterial blood flow

a nurse is preparing to admin furosemide to a client who has heart failure, which of the following findings should the nurse report before administering the med?

Decreased potassium r-Decreased potassium

a nurse is collecting data from a client who has heart failure and is taking digoxin. which of the following outcomes from the med should the nurse expect? a. Increased weight b. Increased heart rate c. Decreased urinary output d. Decreased shortness of breath

Decreased shortness of breath r- The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion. digoxin lowers HR

a nurse is caring for a client who has a prescription for phenazopyridine. which of the following findings should the nurse identify as a therapeutic effect of the medication?

Decreases pain during urination Phenazopyridine reduces pain and burning during urination by exerting an anesthetic effect on the mucosa of the urinary tract.

a nurse is caring for a client who is scheduled for a surgery and is experiencing anxiety. which of the following interventions should the nurse identify as the priority? a. Determine the client's understanding of the procedure. b. Encourage the client to express their feelings. c. Allow the client's partner to stay with them. d. Provide music as a distraction.

Determine the client's understanding of the procedure. r-When using the nursing process, the first action the nurse should take is to collect data from the client. Therefore, the nurse should determine the client's understanding of the procedure to reinforce necessary teaching, which can help manage their anxiety.

a nurse is assisting the charge nurse with dev. an in-service about caring for clients who have internal sealed radiation implants. which of the following info should the nurse include? a. Restrict the time pregnant women are allowed in the client's room to 15 min. b. Pick up a radiation implant with a double-gloved hand if it becomes dislodged. c.Limit time spent in the client's room to 2 hr during an 8 hr shift. d.Dispose of radiation implants in a lead container.

Dispose of radiation implants in a lead container. Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation implants in a lead container in accordance with facility protocol.

a nurse is caring for a client who is postoperative and has an epidural infusion. which of the following findings should the nurse recognize as the priority?

Dyspnea r-When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is dyspnea, which is a complication of the epidural infusion.

a nurse is collecting data froma aclient who has hypokalemia, which of the followign findings should the nurse identify as the priority?

Dysrhythmia When using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding for a client who has hypokalemia is dysrhythmia.

a nurse is caring for a client who is receiving chemotherapy. the client mentions that they have a loss of appetite because of the sores in their mouth and that food no longer tastes good, which of the following suggestions to the client should the nurse make? a. Drink water before and after each bite. b. Consume foods that are served hot rather than cold. c. Rinse with a glycerin-based mouthwash before meals. d.Eat several, small-portioned meals daily.

Eat several, small-portioned meals daily. Clients who have difficulty eating because of pain or anorexia can usually tolerate small amounts of food at one time. Eating several small meals daily can increase the client's caloric intake.

a nurse is contributing to the plan of care for a client who has COPD and is dyspneic. which of the following interventions should the nurse include in the plan? a. encourage abd breathing b. direct the client to inhale w/ a pursed lips c. set the O2 therapy at 5L/min d. intruct the client to lean back when coughing

Encourage abdominal breathing. r- the nurse should encourage abdominal breathing, which reduces the workload on the accessory muscles of respiration during dyspneic episodes.

a nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. which of the following interventions should the nurse include? a. Apply hot packs to the client's muscles. b. Schedule physical therapy in the afternoon. c. Encourage the client to complete ADLs. d. Administer valerian to promote sleep.

Encourage the client to complete ADLs. The nurse should encourage the client to complete ADLs and provide assistance as needed. Performing self-care increases the client's independence, strength, and level of functioning.

a nurse is contributing to the plan of care for the client who is at risk for osteoporosis. which of the following interventions should the nurse include to prevent bone loss? a. Increase fluid intake. b. Encourage range-of-motion exercises. c. Massage bony prominences. d. Encourage weight-bearing exercises.

Encourage weight-bearing exercises. r-Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis. ROM does not prevent bone loss

a nurse is contributing to the plan of care for a client who has partial hearing loss, which of the following interventions should the nurse include in the plan of care? a. Face the client while speaking. b. Use a high-pitched tone when talking to the client. c. Avoid using gestures when communicating. d. Repeat misunderstood phrases.

Face the client while speaking. r-The nurse should face the client, which allows the client to see who is speaking, read the nurse's lips, and obtain visual cues by observing facial expressions.

a nurse is contributing to the plan of care for a client who has MRSA infection and is on contact isolation precautions, which of the following actions should the nurse take?

Have a designated stethoscope in the client's room. r-The nurse should designate equipment to leave in the client's room to avoid cross-contamination. The designated equipment should be disposed of or decontaminated before leaving the client's room.

a nurse is participating in a health fair for older adult clients. which of the following vaccines should the nurse recommend for this age group?

Herpes zoster The nurse should recommend the herpes zoster vaccine for adults who are 60 years of age and older.

a nurse is reviewing the lab results of a client who has chronic kidney failure and is receiving epoetin alfa. the nurse should identify that which of the following lab values indicates the treatment is effective?Hgb 11 g/dL

Hgb 11 g/dL r-Epoetin alfa stimulates the production of erythropoietin and red blood cells, resulting in increased hemoglobin levels. Therefore, a hemoglobin level of 11 g/dL indicates the epoetin alfa treatment is effective.

a nurse is collecting data from a 55 yr female client who reports vaginal dryness and hot flashes, the client is interested in trying hormone replacement therapy. which of the following should the nurse recognize as a contraindication to HRT?

History of treatment for blood clots Estrogen increases the risk for blood clots. Therefore, a female client who has a history of blood clots should not receive HRT.

a nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. when listening in the left upper quadrant, the nurse should identify this sound as which of the following?

Hyperactive bowel sounds r-A mechanical bowel obstruction prevents a portion or all of the bowel contents from moving forward through the bowel. The nurse should expect to auscultate high-pitched, hyperactive bowel sounds above the point of the intestinal obstruction as the intestines attempt to propel the blockage forward.

a nurse is contributing to the plan of care of care for a client who is having difficulty eating following a stroke, which of the following actions should the nurse take the first?

Implement recommendations from the speech language pathologist. r-The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first intervention the nurse should include in the plan of care is to implement recommendations from the speech language pathologist. A speech language pathologist can conduct a swallow study to determine the client's risk for aspiration, provide teaching to the client regarding swallowing techniques, and recommend the consistency of foods and liquids for the client.

a nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestation of impending death. which of the following manifestations should the nurse include? a. incontinence of the bowel and bladder b. Increase in heart rate c. Warmness of the skin d. Hypertension

Incontinence of the bowel and bladder r-The nurse should inform the caregiver that incontinence of the bowel and bladder is a manifestation of impending death. Other manifestations include hypotension, bradycardia, restlessness, and coolness of the skin.

a nurse is assisting in the care of client who has manifestation of sepsis. which of the following provider prescriptions should the nurse implement first?

Initiate oxygen at 4 L/min via nasal cannula. r-When using the airway, breathing, circulation approach to client care, the first action the nurse should take is to initiate oxygen. Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's oxygen saturation levels at 95% or greater, which will maximize the ability of the hemoglobin to support the oxygen needs of the body.

a nurse is caring for a client whoh has acute pancreatitis. while providing care, the nurse observes ecchymosis around the umbilicus. the nurse should identify that this is manifestation of which of the following?

Intra-abdominal bleeding Ecchymosis around the umbilicus is a sign of intra-abdominal bleeding, which is a finding consistent with pancreatitis.

a nurse is collecting data from a client and notices several skin lesions. which of the following findings should the nurse report as possible melenoma? a. Scaly patches b. Silvery white plaques c. Irregular borders d. Raised edge

Irregular borders r-The nurse should report irregular borders of a skin lesion to the provider because it can indicate malignant melanoma.

a nurse is contributing to the plan of care for a client who has admitted to the neurological unit following a stroke 3 hr ago. which of the following interventions should the nurse identify as the priority?

Keep the client in a side-lying position. r-The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying, position to allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction equipment available in the event that any secretions are present in the oral cavity.

a nurse is teaching a client who is on low-sodium diet and asks about how to improve the taste of bland food. which of following foods should the nurse recommend?

Lemon juice r-The nurse should recommend that the client use lemon juice to flavor their food because it is low in sodium.

a nurse is assisting a client who reports difficulty falling asleep, which of the following activities should the nurse recommend to promote sleep?

Listen to soft music before sleeping. r- Listening to soft music can help the client to relax and reduces environmental stressors.

a nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. which of the following actions should the nurse take?

Loosen clothing around the client's neck r-Loosen clothing around the client's neck.

a nurse is caring for a client who is 3 days postoperative following a total right hip arthoplasty. which of the following actions should the nurse take?

Maintain abduction of the client's right leg while in bed. r-The nurse should maintain abduction of the client's right leg to prevent dislocation of the affected hip by placing an abductor pillow between the client's legs when resting in bed.

a nurse is assisting with the care of a client who had a cardiac catheterization via the R femoral A. which of the following actions should the nurse take to prevent postprocedure complications? select all apply

Maintain the pressure dressing is correct. The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for the cannulation site to heal.Check the client's peripheral pulses is correct. The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion. Monitor the insertion site for bleeding is correct. The nurse should monitor the client's insertion site for manifestations of hemorrhaging.

a nurse is caring for a client who has an area indicating potential breakdown over the sacrum. which of the following actions should the nurse take?

Minimize the time the head of the bed is elevated. r-The nurse should minimize the time the head of the bed is elevated to reduce pressure on the sacral area.

a nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. which of the following should the nurse include in the teaching? a. Mohs surgery is a horizontal shaving of thin layers of the tumor. b. Mohs surgery uses liquid nitrogen to destroy the cancerous tissue. c. Mohs surgery is the preferred treatment for melanoma skin cancer. d. Mohs surgery is a palliative treatment for metastatic skin cancer.

Mohs surgery is a horizontal shaving of thin layers of the tumor. r-Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure, which involves a horizontal shaving of thin layers of a tumor, has a high success rate.

a nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthoplasty. which of the following instructions should the nurse include in the discharge plan?

Obtain a raised toilet seat.

a nurse is monitoring a client who has a hx of an enlarged prostate and is experiencing suprapubic discomfort. which of the following actions should the nurse take first?

Palpate the abdomen. When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should palpate the abdomen to determine if the client has a distended bladder from urinary retention.

a nurse is caring for a client who has a compound fracture of the femur and who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. which of the following actions should the nurse take? a. Perform pin site care daily. b. Remove the overbed trapeze. c. Remove the boot every 2 hr. d. Keep the weights on a stable, flat surface.

Perform pin site care daily. r-The nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection

a nurse is preparing to remove a clients NG tube. which of the following interventions should the nurse take to decrease the riskfor aspiration?

Pinch the NG tube. The nurse should pinch the NG tube to prevent secretions from draining into the client's throat, which can cause aspiration.

a nurse is caring for a client who is at risk for dev. pressure injuries, which of the following actions should the nurse take?

Position pillows between the bony prominences. The nurse should use positioning devices to keep bony prominences from being in direct contact with each other, which will prevent skin breakdown and pressure injury development.

a nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. the client is exhibiting hypotension, tachycardia, and tachypnea. the nurse should recognize that these findings indicate which of the following complications?

Pulmonary embolism r-Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea.

a nurse is reinforcing discharge teaching for the caregivers of a client who has parkisons disease. which of the following info should the nurse include in the teaching?

Remind the client to avoid watching their feet when walking. The nurse should instruct the client's caregivers to frequently remind the client to maintain correct posture and prevent falls by not watching their feet when walking.

a nurse is reinforcing discharge teaching about wound care with the caregiver of a client who is postoperative. which of the following should the nurse include in the teaching? a. Administer an analgesic following wound care. b. Irrigate the wound with povidone iodine. c. Cleanse the wound with a cotton-tipped applicator. d. Report purulent drainage to the provider.

Report purulent drainage to the provider. The nurse should remind the caregiver to report manifestations of infection, including purulent drainage, to the provider.

a nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. which of the following findings should indicate to the nurse that the client might have a fecal impaction?

Small liquid stools r-Small liquid stools can be the result of fecal material being expelled around an impaction.

a nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. 10 mins after beginning the infusion, the client reports intense itching, which of following actions should the nurse take 1st?

Stop the medication infusion. r-The greatest risk to the client is injury from an allergic response to the medication. Therefore, the first action the nurse should take is to stop the medication infusion.

a nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN, the client reports dyspenea and uriticaria, after stopping the infusion, which of the following actions should the nurse take next?

Take the client's vital signs. r-The first action the nurse should take when using the nursing process is to collect data from the client to determine what actions should be taken next.

a nurse is reinforcing teaching about home care with a client who had knee arthoplasty. which of the following factors should the nurse identify as an indication that a barrier to learning might be present?

The client stops the nurse and asks for pain medication. The nurse should identify that a client who is in pain will not be able to concentrate, which can interfere with their ability to learn.

a nurse is assisting in the plan of care for client who had a recent Left hemispheric stroke, which of the following should the nurse include in the plan? a. Observe for impulsive behavior. b. Approach the client from the right side. c. Use simple verbal cues when directing tasks. d. Place the client in low-Fowler's position during meals.

Use simple verbal cues when directing tasks. r-he nurse should expect a client who had a left hemispheric stroke to manifest some degree of expressive and/or receptive aphasia. Using simple verbal cues will assist the client in understanding spoken communication.

a nurse is preparing to suction a client who has a tracheostomy, which of the following actions should the nurse take 1st?

Ventilate the client with 100% oxygen. r-According to evidence-based practice, the first action the nurse should take is to ventilate the client with 100% oxygen before suctioning to prevent hypoxemia when removing air and debris from the upper airway.

a nurse is caring for a client who has MRSA infection in a surgical wound. which if the following should the nurse plan to share with visitors?

Visitors must don a gown and gloves prior to entering the client's room. r-The nurse should provide teaching to the visitors regarding the infection control measures for a client who is on contact isolation precautions. Contact precautions require visitors to put on a gown and gloves prior to entering the room of a client who has MRSA to prevent the spread of infection.

a nurse is caring for a client who has a new cast on their left forearm and reports severe pain in the affected arm with numbness in the fingers. the nurse finds the skin place and cold with sluggish capillary refill. which of the following fracture complication should the nurse suspect?

compartment syndrome Compartment syndrome is a complication that involves increased pressure within a compartment (an area that supports blood vessels, bones, and nerves) leading to circulatory compromise to the limb. The pressure can be caused externally by a cast that is too tight or internally by the inflammation or edema from the injury. Circulatory impairment causes pallor and paresthesia of the extremities, a delay in capillary refill, and, without immediate treatment, can cause nerve damage and necrosis.

a nurse is reinforcing discharge teaching with a client who has cirrhosis. which of the following instructions should the nurse include?

consume foods that are low in sodium r-The nurse should instruct the client to consume foods that are low in sodium to reduce the development of edema and ascites.

a nurse is assisting in the plan of care regarding bowel retaining for a client who has cervical spinal cord injury. which of the following interventions should the nurse plan to implement?

determine the client's daily elimination habits. r-The first action the nurse should take when using the nursing process is to collect data on the client's daily bowel elimination habits to establish a routine defecation time.

a nurse is reinforcing teaching about management of constipation with a client who has hyperthyroidism. which of the following instructions should the nurse include in the teaching? a. Increase intake of fiber-rich foods. b. Take a laxative every morning. c. Maintain a fluid intake of 1,200 mL/day. d. Limit activity to preserve energy.

increase intake of fiber-rich foods. r-The nurse should instruct the client to increase the amount of fiber-rich foods in their diet. Dried beans and brown rice are examples of fiber-rich foods.

a nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis, which of the following interventions should the nurse include in the plan?

instruct the client to swish the medication in their mouth. r-The nurse should instruct the client to place half the dose in each side of their mouth, swish the medication, and then swallow. This action will allow the medication to coat the entire oral mucosa and treat the fungal infection.

a nurse is contributing to the plan of care for a patient who is postoperative following a total knee arthroplasty. the client is using a continuous passive motion machine, which of the following interventions should the nurse recommend for the plan of care? a. store a CPM machine on the floor when it is not in use b. keep a sheepskin pad between the client's extremity and the CPM machine c. check the cycle and ROM settings BID d. align the frame joint of the CPM machine w/ the middle calf of the client's calf

keep a sheepskin pad between the client's extremity and the CPM machine. r-The nurse should plan to keep a sheepskin pad between the client's extremity and the CPM machine to protect the client's skin. The nurse should check the client's skin condition frequently while the client is using the CPM machine.

a nurse is caring for a client who is in Bucks' traction, which of the following interventions should the nurse perform to reduce skin breakdown?

keep the skin dry and free pf perspiration r-The nurse should not leave moisture on the skin for prolonged periods of time because it can cause skin breakdown.

a nurse is caring for a client who has meningococcal pneumonia, which of the following ppe should the nurse use? a. gown b. Mask c. Sterile gloves d. Protective eyewear

mask r-the nurse should identify that a client who has meningococcal pneumonia requires droplet precautions, which include wearing a mask when providing care within 1 m (3 feet) of the client.

a nurse is reviewing the lab results of a client who has type 2 diabetes mellitus. the nurse should identify that which of the following lab values indicates the client is at risk for delayed wound healing?

prealbumin 12 mg/dL r-This laboratory value is below the expected reference range, indicating that the client's protein status is inadequate and that they are at risk for delayed wound healing due to malnutrition.

a nurse is examining a client's IV site and notes a red line up their arm. the client reports a throbbing,burning pain at the IV site. the nurse should identify that the client's manifestation indicate which of the following complications of IV therapy? a. thrombophlebitis b. Infiltration c. Hematoma d. Venous spasms

thrombophlebitis r-The nurse should identify pain, warmth, and a red streak up the arm as indications of thrombophlebitis.