NR304 Exam 1

A nurse is administering morphine 2mg IV every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects? A. Diarrhea B. Heartburn C. Hiccups D. Orthostatic hypotension

D. Orthostatic hypotension

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply). A. Excessive laxative use B. Ignoring the urge to defecate C. Inadequate fluid intake D. Increased fiber in the diet E. Increased activity

A. Excessive laxative use B. Ignoring the urge to defecate C. Inadequate fluid intake

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis? A. Myringotomy B. Laparoscopic appendectomy C. Hip arthroplasty D. Cataract extraction

C. Hip arthroplasty

A nurse is caring for who reports an area of redness, warmth, tenderness, and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding? A. Obtain a venous duplex ultrasound B. Obtain impedance plethysmography C. Monitor Homan's sign D. Apply cold therapy to the affected leg

A. Obtain a venous duplex ultrasound

A nurse is providing discharge teaching ti a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching? A. Apply a heating pad on a low setting to help relieve leg pain B. Adjust the thermostat so that the environment is warm C. Wear antiembolic stockings during the day D. Rest with the legs above heart level

B. Adjust the thermostat so that the environment is warm

A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in the teaching? A. Teach the client how to use the PCA pump B. Instruct the client about the use of a sequential compression device C. Discuss the visitation policy D. Review the pain scale

B. Instruct the client about the use of a sequential compression device

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? A. Elevating the feet B. Massaging her legs C. Flexing her ankles D. Ambulating soon after surgery

B. Massaging her legs

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? A. The client will list foods that are high in calcium, which should be avoided. B. The client will walk for 30min 5 days a week. C. The client will increase calorie intake by 200 calories per day. D. The client will replace cigarettes with smokeless tobacco products.

B. The client will walk for 30min 5 days a week.

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make? A. "They protect your legs and heels from skin breakdown." B. "They help keep you warm after you're surgery." C. "They improve your circulation to keep blood from pooling in your legs." D. "They make it easier for you to do leg exercises after your surgery."

C. "They improve your circulation to keep blood from pooling in your legs."

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching? A. Bear down hard when defecating B. Drink four to five glasses of water daily C. Increase dietary intake of raw vegetables D. Limit activity

C. Increase dietary intake of raw vegetables

A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk? A. Triglycerides 130mg/dL B. Blood glucose 92mg/dL C. LDL 172mg/dL D. HDL 84mg/dL

C. LDL 172mg/dL

A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4mg IV bolus every 6 hours as needed. Before administering this medication, the nurse should complete which priority assessment? A. Blood pressure B. Apical heart rate C. Respiratory rate D. Temperature

C. Respiratory rate

A nurse is assessing four female clients for obesity. Which of the following have manifestations of obesity? A. A client who has a body fat of 22% B. A client who has a BMI of 28 C. A client who has a waist circumference of 81.3cm (32in). D. A client who weighs 28% above ideal body weight.

D. A client who weighs 28% above ideal body weight.

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." B. "I will call the provider to get a prescription for discontinuing the IV heparin today." C. "Both heparin and warfarin work together to dissolve the clots." D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay."

A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease? A. Intermittent claudication B. Dependent rubor C. Rest pain D. Foot ulcers

A. Intermittent claudication

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet? A. "I flavor my meat with lemon juice." B. "I eat two eggs for breakfast each morning." C. "I cook my food with canola oil." D. "I take an omega-3 supplement daily."

B. "I eat two eggs for breakfast each morning."