NUR 2051 Module 2

What food should the nurse instruct a client to avoid when prescribed digoxin? (Select all that apply) 1. Black licorice 2. Coenzyme Q-10 3. Grapefruit 4. Grapes 5. Wheat bran

1. Black licorice 5. Wheat bran

A nurse is caring for a client post heart catheterization with a left femoral stick. What signs and symptoms would indicate to the nurse that the primary healthcare provider should be notified? (Select all that apply) 1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4 5. Temperature of 99.9º F (37.72º C)

1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4

A nurse, planning an educational seminar on chronic kidney disease, would invite clients with which medical conditions? (Select all that apply) 1. Diabetes 2. Frequent urinary tract infections (UTI) 3. Hyperlipidemia 4. Hypertension 5. Obesity

1. Diabetes 3. Hyperlipidemia 4. Hypertension 5. Obesity

A manufacturing worker comes into the occupational health nurse's clinic reporting a squeezing pain in the chest. What additional signs and symptoms should the nurse monitor for in the client? (Select all that apply) 1. Dyspnea 2. Dry, flushed skin 3. Indigestion 4. Restlessness 5. Tachycardia

1. Dyspnea 3. Indigestion 4. Restlessness 5. Tachycardia

A nurse is attempting planning care for a client who has self-care difficulty due to left-sided hemiparesis. Which intervention should the nurse include? (Select all that apply) 1. Offer to take the client to the toilet every two hours. 2. Instruct client to use disposable razors once to prevent infection. 3. Encourage family members to comb hair for client. 4. Provide the client with a button hook for dressing. 5. Teach the client to rely on furniture for support when walking.

1. Offer to take the client to the toilet every two hours. 4. Provide the client with a button hook for dressing.

What assessment finding would indicate to the nurse that further treatment is needed for a client hospitalized with systolic heart failure? (Select all that apply) 1. S3 heart sound 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.91 kg) 4. Hepatomegaly 5. Increasing BNP level 6. Urine output at 50 mL/hr

1. S3 heart sound 4. Hepatomegaly 5. Increasing BNP level

A client was admitted two days ago in the oliguric phase of acute kidney injury (AKI). What evaluation by the nurse would indicate that treatment has been effective? (Select all that apply) 1. Variable urine specific gravity 2. Serum K+ 5.5 mEq (5.5 mmol/L) 3. Serum Na+ 140 mEq (140 mmol/L) 4. Minimal crackles auscultated in bases of left lung 5. Urine output = 1250 mL/24 hours

1. Variable urine specific gravity 3. Serum Na+ 140 mEq (140 mmol/L) 5. Urine output = 1250 mL/24 hours

The nurse is planning care for a client diagnosed with pyelonephritis. What interventions should a nurse include? (Select all that apply) 1. Advise that urine may turn blue with administration of nitrofurantoin. 2. Encourage voiding every 2 hours. 3. Educate the client that phenazopyridine is an antibiotic used to treat pyelonephritis. 4. Palpate the bladder every 4 hours. 5. Provide client with at least 1500 mL of water to drink daily.

2. Encourage voiding every 2 hours. 4. Palpate the bladder every 4 hours.

A client arrives to the emergency department with reports of palpitations, chest discomfort, and light-headedness. The nurse connects the client to a cardiac monitor and notes a weak, thready pulse, and a BP of 90/50. What actions should the nurse take? ECG = SVT (Select all that apply) 1. Administer Atropine 0.5 mg intravenous push (IVP). 2. Prepare for immediate synchronized cardioversion. 3. Provide 100 percent oxygen. 4. Start large bore intravenous access. 5. Set up for endotracheal intubation.

2. Prepare for immediate synchronized cardioversion. 4. Start large bore intravenous access.

A home heath nurse is educating a client about home care considerations for clean intermittent catheterization. Which statement made by the client would indicate to the nurse that further teaching is needed? 1. "I will wash the re-usable catheter thoroughly with soap and water after use." 2. "When urine stops flowing, I will press over the bladder area with my free hand." 3. "It is important that maintain sterile technique when catheterizing myself." 4. "Catheterization should be done when I feel the need to void."

3. "It is important that maintain sterile technique when catheterizing myself."

A small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first? 1. Assess the immediate area for electrical wires on the ground. 2. Attend to victim injuries as they are encountered. 3. Activate the community emergency response team. 4. Triage and tag victims according to injury.

3. Activate the community emergency response team.

When an explosion occurs at a local shopping center, an off-duty nurse quickly begins to triage those injured. The nurse knows which client needs immediate attention? 1. An elderly adult with a traumatic left eye enucleation. 2. A child with an open, compound fracture of the femur. 3. An adult with a head laceration bleeding profusely. 4. An adolescent with a rigid, board-like lower abdomen.

4. An adolescent with a rigid, board-like lower abdomen. (Internal bleeding)

The nurse is planning care for a client who has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which intervention would the nurse include in this plan? (Select all that apply) 1. After voiding, instruct client to void a second time. 2. Encourage the client to void every 4 hours. 3. Teach client to perform the Credé method. 4. Pour warm water over perineum. 5. Insert indwelling urinary catheter if client unable to void.

1. After voiding, instruct client to void a second time. 2. Encourage the client to void every 4 hours. 3. Teach client to perform the Credé method. 4. Pour warm water over perineum.

The nurse is assessing a client admitted with a diagnosis of chronic renal failure. Which finding would the nurse expect to see in the client? (Select all that apply) 1. Anemia 2. Fluid volume deficit 3. Pruritis 4. Dependent edema 5. Hypokalemia

1. Anemia 3. Pruritis 4. Dependent edema

The nurse is assessing a male client suspected of having a myocardial infarction (MI). What signs/symptoms would the nurse expect the client to exhibit? (Select all that apply) 1. Bradycardia 2. Chest pressure 3. Cough 4. Flu like symptoms 5. Vomiting

2. Chest pressure 3. Cough 5. Vomiting

The nurse is caring for a client with acute renal failure. The morning assessment findings indicate the client has become confused and irritable. Which finding is most likely responsible for the change in behavior? 1. Hyperkalemia 2. Hypernatremia 3. Elevated blood urea nitrogen (BUN) 4. Limited fluid intake

3. Elevated blood urea nitrogen (BUN)

A client returns to the unit after having extracorporeal lithotripsy. Which would be the best indicator that the treatment has been effective? 1. The client is relieved of the pain. 2. The urine is free of red blood cells. 3. The urinary output has increased since return to the unit. 4. There is sediment in the urinary catheter drainage bag.

4. There is sediment in the urinary catheter drainage bag.

The nurse is monitoring the client's heart rhythm. The monitor shows sinus tachycardia. What is expected with this assessment finding? (Select all that apply) 1. Regular rhythm 2. Rate of 101-200 3. Absent P wave 4. P-R interval not measurable 5. QRS complex greater than 0.20 seconds

1. Regular rhythm 2. Rate of 101-200

What potential contributing factors for transient urinary incontinence should a nurse assess in an elderly female client? (Select all that apply) 1. Chronic urinary retention 2. Fecal impaction 3. Menopause 4. Restricted mobility 5. Stroke

2. Fecal impaction 4. Restricted mobility

A client has been admitted with advanced cirrhosis. The nurse's assessment verifies an increase weight of 6 lbs. (2.71 kg) since yesterday's weight and an abdominal girth increase of 5 inches (12.7 cm). What is the priority assessment? 1. Urinary Output 2. Daily weight 3. Blood pressure 4. LOC

3. Blood pressure

During the admission examination of a client diagnosed with acute pyelonephritis, what signs or symptoms would the nurse expect to find? (Select all that apply) 1. Dysnea 2. Hematuria 3. Pubic pain 4. Tachycardia 5. Weight gain

2. Hematuria 4. Tachycardia 5. Weight gain

A community health nurse is presenting a seminar to a group of senior citizens on ways to reduce the risks of peripheral artery disease (PAD). What topics should the nurse include? (Select all that apply) 1. Daily strenuous exercise 2. How to read food labels 3. Maintaining a BMI less than 30 kg/m2 4. Managing diabetes 5. Use of anti-embolic stockings

2. How to read food labels 4. Managing diabetes

A client had a coronary artery bypass surgery (CABG) x 3 performed 24 hours ago. What assessment findings would make the nurse suspect cardiac tamponade? (Select all that apply) 1. Bradycardia with wet lungs 2. Increased central venous pressure 3. Distended bilateral neck veins 4. A widening pulse pressure 5. Decreasing blood pressure

2. Increased central venous pressure 3. Distended bilateral neck veins 5. Decreasing blood pressure

What should a nurse include when planning an educational program for a group of women on how to prevent a urinary tract infection (UTI)? (Select all that apply) 1. Empty bladder at least every 8 hours while awake 2. Take showers rather than prolonged baths 3. Use spemicidal jelly during intercourse 4. Use tampons rather than sanitary napkins 5. Wear cotton underwear

2. Take showers rather than prolonged baths 4. Use tampons rather than sanitary napkins 5. Wear cotton underwear

A client who has been diagnosed with chronic venous insufficiency has received teaching regarding how to prevent venous stasis ulcerations. Which statements by the client indicate to the nurse that teaching has been effective? (Select all that apply) 1. "Stationary standing should be kept to a minimum." 2. "It is important to avoid wearing constricting clothes longer than 2 hours." 3. "Protecting my legs from trauma is very important." 4. "I will wear compression stockings every day." 5. "I will elevate the foot of my bed 6 inches (15.24 cm) when I sleep."

1. "Stationary standing should be kept to a minimum." 3. "Protecting my legs from trauma is very important." 4. "I will wear compression stockings every day." 5. "I will elevate the foot of my bed 6 inches (15.24 cm) when I sleep."