NURS 3661 Exam 3 Part 1

The nurse is instructing a client with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the client?

Administer the iron through a straw.

The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor?

Age younger than 50 years

The nurse is preparing discharge instructions for a client who sustained a skeletal muscle injury and is receiving baclofen. Which instruction should be included in the teaching plan?

Avoid the use of alcohol.

The nurse is caring for a client who is postoperative following a pelvic exenteration, and the surgeon changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priority item before administering the diet?

Bowel sounds

The nurse is administering an intravenous dose of methocarbamol to a client with a muscle skeletal injury. For which adverse effect should the nurse monitor?

Bradycardia

The nurse, who is administering bethanechol chloride, is monitoring for cholinergic overdose associated with the medication. The nurse should check the client for which sign of overdose?

Bradycardia

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder?

Dysuria and penile discharge

The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign or symptom of this oncological emergency?

Electrocardiographic changes

The nurse is reviewing a client's record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

Elevated creatinine level

The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg?

Elevated on pillows continuously for 24 to 48 hours

The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?

Elevating the affected arm on a pillow above heart level

The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?

Encouraging fluids

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client?

Enlarged lymph nodes

The nurse is reviewing the laboratory results for a client receiving tacrolimus. Which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication?

Fasting blood glucose of 200 mg/dL (11.1 mmol/L)

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

Notify the primary health care provider (PHCP).

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5° C (101.2° F). Which nursing action is most appropriate?

Notify the primary health care provider.

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome?

Numbness and tingling in the fingers

While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action?

Pick up the implant with long-handled forceps and place it in a lead container.

The nurse is assessing the casted extremity of a client. Which sign is indicative of infection?

Presence of a "hot spot" on the cast

The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take?

Rewrap the residual limb with an elastic compression bandage.

Nitrofurantoin is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports a cough, chills, fever, and difficulty breathing. The nurse should make which interpretation about the client's complaints?

The client is experiencing a pulmonary reaction requiring cessation of the medication.

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?

Thick, yellow drainage from the pin sites

The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client?

Uric acid level of 9.0 mg/dL (540 mcmol/L)

Bethanechol chloride is prescribed for a client with urinary retention. Which disorder would be a contraindication to the administration of this medication?

Urinary strictures

Phenazopyridine is prescribed for a client with a urinary tract infection. The nurse evaluates that the medication is effective based on which observation?

Urination is not painful.

The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood?

"I need to report a fever or swelling to my health care provider."

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?

"I'm going to take aspirin for my headache as soon as I get home."

A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client?

"You need to consult with the primary health care provider (PHCP) before receiving immunizations."

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 50,000 mm3 (50 × 109/L)

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this problem?

A sedentary 65-year-old woman who smokes cigarettes

During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease?

Abdominal distention

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor?

Bending or lifting

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention ismost appropriate?

Change the dressing as prescribed.

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus?

Clear mentation

A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication?

Decongestants

Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction should the nurse provide?

Drink 3000 mL of fluid a day.

Cyclobenzaprine is prescribed for a client for muscle spasms, and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the primary health care provider about the administration of this medication?

Glaucoma

The nurse is providing dietary instructions to a client who has been prescribed cyclosporine. Which food item should the nurse instruct the client to exclude from the diet?

Grapefruit juice

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain?

Impaired tissue perfusion

The nurse is providing medication instructions to a client with breast cancer who is receiving cyclophosphamide. The nurse should tell the client to take which action?

Increase fluid intake to 2000 to 3000 mL daily.

The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder?

Increased calcium level

A week after kidney transplantation, a client develops a temperature of 101° F (38.3° C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment?

Increased immunosuppression therapy

Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to perform which assessment before administering chemotherapy?

Measure the client's current weight and height.

A client is admitted to the emergency department following a fall from a horse, and the primary health care provider (PHCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action?

Notify the PHCP before performing the catheterization.

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?

One week after menstruation begins

The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse contacts the primary health care provider before administering the medication if which disorder is documented in the client's history?

Pancreatitis

The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency?

Periorbital edema

A client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which manifestation indicates an adverse effect specific to this medication?

Peripheral neuropathy

A client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed?

Pulmonary function studies

Oxybutynin chloride is prescribed for a client with urge incontinence. Which sign would indicate a possible toxic effect related to this medication?

Restlessness

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery?

Separation of the wound edges

Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it develops during the course of this medication therapy?

Sore throat

Alendronate is prescribed for a client with osteoporosis, and the nurse is providing instructions on administration of the medication. Which instruction should the nurse provide?

Take the medication with a full glass of water after rising in the morning.

Tacrolimus is prescribed for a client who underwent a kidney transplant. Which instruction should the nurse include when teaching the client about this medication?

Take the oral medication every 12 hours at the same times every day.

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?

The client's pain rating

A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition?

The development of a vesicovaginal fistula

A client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication?

Uric acid level

Megestrol acetate, an antineoplastic medication, is prescribed for a client with metastatic endometrial carcinoma. The nurse reviews the client's history and should contact the primary health care provider if which diagnosis is documented in the client's history?

Venous thromboembolism

Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The client asks the nurse if her family member with bladder cancer can also take this medication. The nurse most appropriately responds by making which statement?

"This medication can be taken to prevent and treat clients with breast cancer."

The nurse receives a call from a client concerned about eliminating brown- colored urine after taking nitrofurantoin for a urinary tract infection. The nurse should make which appropriate response?

"Continue taking the medication; the brown urine occurs and is not harmful."

The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?

"I empty the urinary collection bag when it is two-thirds full."

A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast?

"I need to avoid getting the cast wet."

Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?

Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L)

A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the primary health care provider (PHCP)?

Blood pressure, 100/50 mm Hg; pulse, 130 beats per minute

A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication?

Calcium level

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?

Continue to monitor the drainage.

A client with non-Hodgkin's lymphoma is receiving daunorubicin. Which finding would indicate to the nurse that the client is experiencing an adverse effect related to the medication?

Crackles on auscultation of the lungs

The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia?

Decreased force in the stream of urine

The nurse is providing discharge instructions to a client receiving trimethoprim-sulfamethoxazole. Which instruction should be included in the list?

Drink 8 to 10 glasses of water per day.

The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination?

Fever, nausea, vomiting, and painful scrotal edema

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations?

Headache, deteriorating level of consciousness, and twitching

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication?

Hematocrit of 33% (0.33)

The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer?

Hematuria

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?

Hyperglycemia

The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy?

Increased uric acid level

A client with a urinary tract infection is receiving ciprofloxacin by the intravenous (IV) route. The nurse appropriately administers the medication by performing which action?

Infusing slowly over 60 minutes

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement?

Injury to the brachial plexus nerves

Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which disorder?

Kidney disease

The nurse is analyzing the laboratory studies on a client receiving dantrolene to treat muscle spasms from an injury. Which laboratory test would identify an adverse effect associated with the administration of this medication?

Liver function tests

A client with small cell lung cancer is being treated with etoposide. The nurse monitors the client during administration, knowing that which adverse effect is specifically associated with this medication?

Orthostatic hypotension

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication?

Pallor, diminished pulse, and pain in the left hand

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

Palpation of a thrill over the fistula.

A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client?

Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

Laboratory studies are performed for a client suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic

The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take?

Stay with the victim and encourage him or her to remain still.

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?

Teach the client and family about the need for hand hygiene.

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding?

Temperature of 101.6° F (38.7° C) orally

A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder?

Tender, indurated prostate gland that is warm to the touch

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure?

That the best time for the examination is after a shower

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?

The passage of flatus

A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess?

The white blood cell counts and platelet counts

A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition?

Trauma to the bladder or abdomen