NUS 210 Final PrepU
A client is admitted to a health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?
Impaired gas exchange related to airflow obstruction
An older adult patient has been admitted to a medical unit, and the nurse is conducting a comprehensive assessment of the patient in order to plan care appropriately. Which of the nurse's following assessments directly relate to the known risk factors for cardiovascular disease?
Measuring the patient's random glucose level Measuring the patient's blood pressure
Which of the following is the priority nursing diagnosis for the client in the oliguric phase of acute renal failure?
Fluid volume excess
A nurse is preparing to administer prescribed antipsychotic medication to a client with psychosis. The nurse identifies the prescribed medication as a first-generation antipsychotic drug. Which drug would the nurse most likely be administering?
Fluphenazine
A 62-year-old woman diagnosed with breast cancer is scheduled for a partial mastectomy. The oncology nurse explained that the surgeon will want to take tissue samples to ensure the disease has not spread to adjacent axillary lymph nodes. The client has asked if she will have her lymph nodes dissected, like her mother did several years ago. What alternative to lymph node dissection will this client most likely undergo?
Sentinel node biopsy
For a client with chronic obstructive pulmonary disease, which nursing intervention helps maintain a patent airway?
Teaching the client how to perform controlled coughing
The nurse is teaching the client with HIV about therapy. Which elements are essential for the nurse to include in the teaching plan? Select all that apply.
The CD4 count is the major indicator of immune function and guides therapy. Antiretroviral therapy targets different stages of the HIV life cycle.
Assessment of violence potential is an important part of nursing care on the inpatient unit. Which is an indicator that the client with schizophrenia may be at high risk for violence while in the hospital?
The client assaulted an officer prior to admission.
A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy?
The client demonstrates ability to tolerate more activity without chest pain.
A client has received the results of a HIV antibody test, which is positive. What is the best explanation for the nurse to give to the client?
The client has been infected and has produced antibodies.
A client on antiretroviral drug therapy is discussing with the nurse that sometimes he "forgets to take his meds for a few days." What should the nurse inform the client can occur when the medications are not taken as prescribed?
The client is risking the development of drug resistance and drug failure.
A client presents to the emergency department with complaints of acute GI distress, bloody diarrhea, weight loss, and fever. Which condition in the family history is most pertinent to the client's current health problem?
Ulcerative colitis
A patient with suspected esophageal varices is scheduled for an upper endoscopy with moderate sedation. After the procedure is performed, how long should the nurse withhold food and fluids?
Until the gag reflex returns
A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Urine output of 20 ml/hour
During hemodialysis, toxins and wastes in the blood are removed by which of the following?
Diffusion
The client with chronic renal failure is exhibiting signs of anemia. Which is the best nursing rationale for this symptom?
Diminished erythropoietin production
A hospitalized client with schizophrenia is receiving antipsychotic medications. While assessing the client, a nurse identifies signs and symptoms of a dystonic reaction. Which agent would the nurse expect to administer?
Diphenhydramine
Assessment of a client with schizophrenia reveals that the client is hearing voices that tell the client that people are staring at the client and that the client is seeing illusions. When developing the plan of care for this client, which nursing diagnosis would be most appropriate?
Disturbed sensory perception
Which phase of acute renal failure signals that glomerular filtration has started to recover?
Diuretic
A client is in end-stage chronic renal failure and is being added to the transplant list. The nurse explains to the client how donors are found for clients needing kidneys. Which statement is accurate?
Donors are selected from compatible living or deceased donors.
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement?
"I sleep on three pillows each night."
When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to home, the nurse should be sure to include which instruction?
"Avoid sharing such articles as toothbrushes and razors."
Which type of jaundice is the result of increased destruction of red blood cells?
Hemolytic
When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris?
"The pain occurred while I was mowing the lawn."
A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, which expected outcome should a nurse include?
"Client will verbalize the intention to stop smoking."
A client has been recently diagnosed with depression and has just started taking an antidepressant medication. Which of the client's statements indicates an accurate understanding of this aspect of treatment?
"I understand that I probably won't feel much better for a couple of weeks after I start the drugs."
A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, "I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse?
"I understand your concern. The blood is screened very carefully for different viruses as well as HIV."
The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. What response by the nurse would best reassure this patient?
"These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and X-ray studies."
A client with schizophrenia is prescribed clozapine because other prescribed medications have been ineffective. After educating the client and family about the drug, the nurse determines that the education was successful when they state:
"We'll need to make sure that the client has the client's blood count checked at least weekly."
A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response?
"You may have eaten contaminated restaurant food."
Which client is most likely to benefit from electroconvulsive therapy (ECT)?
A client whose major depression has not responded appreciably to antidepressants
The nurse provides care on an oncology unit, where many patients undergo surgery during cancer treatment and face a particularly high risk of deep vein thrombosis (DVT) because of an increase in circulating procoagulants. The nurse should prioritize which type of assessments?
Limb symmetry and calf pain
The nurse is working in a psychiatric-mental health facility and assessing the clients' risk for suicidal behaviors. Which client would be at highest risk?
A client with schizophrenia who has had a previous suicide attempt
Which statement describes emphysema?
A disease of the airways characterized by destruction of the walls of overdistended alveoli
The nurse is educating a client who is required to restrict potassium intake. What foods would the nurse suggest the client eliminate that are rich in potassium?
Citrus fruits
Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following?
Ammonia
The nurse is caring for an asthmatic patient hospitalized with an acute asthma exacerbation. What drugs would the nurse anticipate being ordered for this patient to gain underlying control of persistent asthma?
Anti-inflammatory drugs
When assuming the management of the care of a delusional client, which should be the nurse's priority intervention?
Assure the client that he or she is safe in this milieu
A client has been diagnosed with schizophrenia. Assessment reveals that the client lives alone. The client's clothing is disheveled, the client's hair is uncombed and matted, and the client's body has a strange odor. During an interview, the client's family members voice a desire for the client to live with them when the client is discharged. Based on the assessment findings, which nursing diagnosis would be the priority?
Bathing self-care deficit related to symptoms of schizophrenia
Mrs. Unger is a 53-year-old woman who was diagnosed with breast cancer following a process that began with abnormal screen mammography results. Mrs. Unger, her oncologist, and surgeon have agreed on a mastectomy as treatment and have discussed the importance of rigorously assessing whether her cancer has metastasized. What action will best detect possible metastasis of Mrs. Unger's breast cancer?
Biopsy of the axillary lymph nodes
A client who suffers from bipolar disorder is admitted to a mental health unit for a manic episode. The nurse knows that which takes priority?
Client safety
Other than abstinence, what is the only proven method of decreasing the risk of sexual transmission of HIV infection?
Consistent and correct use of condoms
A patient with a diagnosis of late-stage bladder cancer has experienced a steady decline in his platelet counts, which are currently 18,000/mm3 (0.018 × 1012/L). Which of the following nursing actions best accommodates the health risks associated with this laboratory finding?
Encouraging the patient to increase his fluid intake and providing stool softeners
A nurse advises a woman newly diagnosed with HIV/AIDS about transmission precautions. She mentions that it is safe to:
Engage in casual kissing as long as the skin is not broken.
A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply.
Enlarged liver size Ascites Hemorrhoids
The nurse is assessing a client with schizophrenia who has a history of successfully managing the symptoms. The client has few social activities and speaks in a flat tone when interacting with others. Currently the client is experiencing acute psychosis with active hallucinations and social withdrawal. The nurse identifies improved social skills as an important therapeutic goal. How should the nurse implement this plan?
Enter the client in a social skills training program when acute psychosis subsides.
A client has been taking haloperidol for 5 years when the client is admitted to the inpatient unit for relapse of symptoms of schizophrenia. Upon assessment, the client demonstrates akathisia, dystonia, a stiff gait, and rigid posture. The nurse correctly identifies these symptoms are indicative of what?
Extrapyramidal side effects
A nurse is teaching about risk factors that increase the probability of heart disease to a community group. Which risk factors will the nurse include in the discussion? Select all that apply.
Family history of coronary heart disease Age greater than 45 years for men African-American descent Elevated C-reactive protein
A nurse teaches a client with angina pectoris that he or she needs to take up to three sublingual nitroglycerin tablets at 5-minute intervals and immediately notify the health care provider if chest pain doesn't subside within 15 minutes. What symptoms may the client experience after taking the nitroglycerin?
Headache, hypotension, dizziness, and flushing.
The nurse passes out medications while a client prepares for hemodialysis. The client is ordered to receive numerous medications including antihypertensives. What is the best action for the nurse to take?
Hold the medications until after dialysis.
The nurse recognizes that an older adult patient with heart failure is experiencing the effects of inadequate cardiac output, a problem that affects many of the body's systems. Inadequate perfusion of the patient's kidneys leads to which of the following pathophysiological effects?
Increased renin release
Which of the following would the nurse expect to find when reviewing the laboratory test results of a client with renal failure?
Increased serum creatinine level
A nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?
It helps prevent early airway collapse.
During a routine checkup, a nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?
Kaposi's sarcoma
A patient has developed pulmonary edema during an exacerbation of heart failure. The patient is experiencing dyspnea primarily because of the accumulation of pressure in the patient's:
Left atrium
A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent which condition?
Lymphedema
A nurse is caring for a group of hospitalized clients with various psychiatric diagnoses. The nurse identifies which client as having the highest risk for suicide?
Man with major depressive disorder
The nurse is providing discharge teaching to a patient diagnosed with heart failure. What should the nurse teach this patient to do to monitor fluid balance?
Monitor weight daily
A client with bipolar disorder has been taking lithium, and today the client's serum lithium level is 2.0 mEq/L. What effects would the nurse expect to see?
Nausea, diarrhea, and confusion
A patient who had a recent myocardial infarction was brought to the emergency department with bleeding esophageal varices and is presently receiving fluid resuscitation. What first-line pharmacologic therapy does the nurse anticipate administering to control the bleeding from the varices?
Octreotide (Sandostatin)
A client with a diagnosis of schizophrenia believes that the client is an undercover operative for the Central Intelligence Agency and that voices of various representatives of the organization give the client regular updates on the client's missions. The client is unwilling to participate in many interventions because the client is "too busy with things that are more important than you could possibly understand." The primary theme of the client's delusions is consistent with what?
Paranoia
A nurse is receiving a client with a radioactive implant for the treatment of cervical cancer. What is the nurse's best action?
Place the client in a private room.
A client presents to the ED experiencing symptoms of COPD exacerbation. The nurse understands that goals of therapy should be achieved to improve the client's condition. Which statements reflect therapy goals? Select all that apply.
Provide medical support for the current exacerbation. Treat the underlying cause of the event. Return the client to their original functioning abilities. Provide long-term support for medical management.
A 58-year-old patient's electrocardiogram (ECG) and presentation are suggestive of a myocardial infarction (MI), and treatment has been promptly initiated. The nurse who is part of the patient's care team should anticipate and facilitate which of the following interventions?
Providing the patient with supplementary oxygen Administering morphine by IV
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?
Respiratory alkalosis
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?
Risk for infection
When developing the plan of care for a client with a primary immunodeficiency, which nursing diagnosis would be the priority?
Risk for infection related to altered immune cell function
Which would be the priority diagnosis for the client in the manic phase of bipolar disorder who is exhibiting aggressive behavior?
Risk for other-directed violence
A client at the walk-in clinic reports exposure to human immunodeficiency virus (HIV). The client wants to know the precise sources through which the HIV infection is transmitted. What is the nurse's best response?
Semen
Which is the most common report by clients with pancreatitis?
Severe, radiating abdominal pain
The nurse is preparing to assess a client whose chart documents that the client experienced extravasation when receiving the vesicant vincristine during the previous shift. The documentation also notes that an antidote was administered immediately. The nurse prepares to assess for which conditions? Select all that apply.
Sloughing tissue Tissue necrosis Effectiveness of the antidote
Which of the following are true statements about effective radiation therapy? Select all that apply.
Slower-growing tissues at rest (muscle) are more radioresistant. Tumors that are well oxygenated are more sensitive to radiation. Tumors that are small in size and dividing rapidly are more sensitive.
A client receiving lithium therapy has a plasma blood concentration of 2.2 mEq/L. Which would the nurse expect to assess?
Slurred speech
A client develops acute renal failure (ARF) after receiving IV therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 mL, the nurse suspects that the client is at risk for:
cardiac arrhythmia.
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?
Start IV fluids with a normal saline solution bolus followed by a maintenance dose.
The nurse is working with an outpatient who has a history of depression and suicide attempts. What assessment finding should the nurse interpret as indicating a high degree of planning for a future attempt?
The client recently purchased a large bottle of over-the-counter analgesics
For which client would the nurse be obligated to take immediate and focused action to prevent imminent death?
The client with depression who has been using alcohol and owns a gun
The client asks the nurse why a stress test is needed. What statement best explains the rationale for the health care provider to order a cardiac stress test?
The health care provider wants to identify if the heart failure is from coronary artery disease.
A 50-year-old woman has a long history of hospital admissions related to alcohol abuse and consequent liver failure. During this present admission, the patient has been diagnosed with hepatic encephalopathy and prescribed lactulose (Cephulac). During morning report, the nurse learns that the previous nurse withheld the patient's latest dose of lactulose because the patient had two loose bowel movements during the shift. How should the nurse interpret the previous nurse's action?
The previous nurse should have administered the lactulose because it is necessary to remove excess ammonia.
Which of the following is the single largest preventable cause of cancer?
Tobacco
Which of the following are risk factors for the development of chronic obstructive pulmonary disease (COPD)? Select all that apply.
Tobacco smoke Occupational dust Air pollution Infection Second-hand smoke
Which statement reflects treatment of HIV infection?
Treatment of HIV infection for an individual client is based on the client's clinical condition, CD4 T cell count, and HIV RNA (viral load).
The nurse is responsible for teaching the patient who is receiving head and neck radiation how to protect his mouth. Which of the following teaching points should be included? Select all that apply.
Use a bland mouth rinse before and after meals and at bedtime. Avoid carbonated and caffeinated beverages. Use fluoride preparations daily.
A client is admitted to the emergency department with chest pain and doesn't respond to nitroglycerin. The health care team obtains an electrocardiogram and administers I.V. morphine. The health care provider also considers administering alteplase. This thrombolytic agent must be administered soon after onset of myocardial infarction (MI) symptoms?
Within 6 hours
A client with left-sided heart failure reports increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of what condition?
acute pulmonary edema.
A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:
diminished or absent breath sounds on the affected side.
A client who had coronary artery bypass surgery is exhibiting signs of heart failure. What medications will the nurse anticipate administering for this client? Select all that apply.
diuretics inotropic agents digoxin
A nurse is caring for a client with left-sided heart failure. What should the nurse anticipate using to reduce fluid volume excess?
diuretics.
A client is being released from the inpatient psychiatric unit with a diagnosis of schizophrenia and treatment with antipsychotic medications. After teaching the client and family about managing the disorder, the nurse determines that the education was effective when they state that which should be reported immediately?
elevated temperature
In a client infected with human immunodeficiency virus (HIV), CD4+ levels are measured to determine the:
extent of immune system damage.
Rejection of a transplanted kidney within 24 hours after transplant is termed
hyperacute rejection.
What does the nurse recognize as clinical manifestations consistent with ascites? Select all that apply.
increased abdominal girth rapid weight gain visible distended veins stretch marks
Which set of arterial blood gas (ABG) results requires further investigation?
pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?
pH, 7.25; PaCO2 50 mm Hg
The nurse is administering digoxin to a client with heart failure. What laboratory value may predispose the client to digoxin toxicity?
potassium level of 2.8 mEq/L
Which client requires immediate nursing intervention? The client who:
presents with a rigid, board-like abdomen.
Palliation refers to
relief of symptoms of disease and promotion of comfort and quality of life.
A client diagnosed with acute kidney injury (AKI) has a serum potassium level of 6.5 mEq/L. The nurse anticipates administering:
sodium polystyrene sulfonate (Kayexalate)
A nurse is caring for a client newly diagnosed with cancer. Which therapies are used to treat cancer? Select all that apply.
surgery hyperthermia radiation therapy chemotherapy
A client with COPD is being referred to a pulmonary rehabilitation program. When explaining this program to the client, which information would the nurse most likely include as a reason for it? Select all that apply.
symptom reduction improved quality of life greater participation in activities
A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity?
visual disturbances.
A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor?
weight.
A nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers the client to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation?
"Rehabilitation will help me function as well as I physically can."
A nurse is caring for a recently married, 29-year-old female client, who was diagnosed with acute lymphocytic leukemia. The client is preparing for an allogeneic bone marrow transplant. Which statement by the client demonstrates she understands the informed consent she gave about the diagnosis and treatment?
"I'll only need chemotherapy treatment before receiving my bone marrow transplant."
A nurse is teaching a client who is receiving radiation treatment for left lower lobe lung cancer. Which client statement indicates a need for further teaching?
"I'll use hats to protect my head from the sun when my hair falls out."
A client with major depression is admitted to the health facility and expresses feelings of worthlessness and abandonment by significant others. Which replies by the nurse would convey empathy?
"It sounds like this is a really difficult time for you."
When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. The nurse documents this finding as which of the following?
Caput medusae
When caring for a client with cirrhosis, which symptom(s) should the nurse report immediately?
Change in mental status
A 20-year-old client was admitted to the inpatient unit following a suicide attempt. The client is disheveled, disorganized, and dehydrated. The priority for the client's care during the first 24 hours of admission will be what?
Assessing the client's current suicidal ideation and putting the client on suicide precautions.
Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction?
Asterixis
A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF?
Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL
A nurse is preparing to document information obtained from a client diagnosed with a delusional disorder who is experiencing somatic delusions. Which would the nurse most likely document?
Body complaints
A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by:
Edema and inflammation
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, what would the nurse stress the importance of?
Increasing fluid intake to prevent dehydration
The assessment of a client admitted with increased ascites related to cirrhosis reveals the following: pulse 86 beats per minute and weak, respirations 28 breaths per minute, blood pressure 130/88 mm Hg, and pulse oximetry 90%. Which nursing diagnosis should receive top priority?
Ineffective breathing pattern
Crohn's disease is a condition of malabsorption caused by which pathophysiological process?
Inflammation of all layers of intestinal mucosa
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
Inspecting the skin for petechiae once every shift
The nurse has been asked to teach a patient how to self-administer nitroglycerin. The nurse should instruct the patient to do which of the following? Select all of the teaching points that apply.
Let the tablet dissolve in the mouth and keep the tongue still. The tablet can be crushed between the teeth but not swallowed. Renew the supply every 6 months. Take the tablet in anticipation of any activity that can produce pain. Call emergency services if, after taking three tablets (one every 5 minutes), pain persists.
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important?
Limiting fluid intake
A client was admitted to a critical care unit with esophageal varices and a precarious physical condition. What predisposes the client to have bleeding varices? Select all that apply.
Little protective tissue to protect fragile veins Chemical irritation Straining at stool Rough food
A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure?
Nephrotoxic injury secondary to use of contrast media
A 22-year-old college student has been diagnosed with Crohn's disease after a diagnostic workup that was prompted by his complaints of recurring abdominal pain and diarrhea. The nurse who is contributing to this patient's care should recognize the possibility of which complications of his disease? Select all that apply.
Nutritional deficits Fluid and electrolyte imbalances Intestinal obstruction Fistula
A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure?
Potassium
You are giving a report in your pathophysiology class. The subject of your report is cancer cells. In differentiating between benign and malignant cells, what characteristics would you cite? Select all that apply.
Rate of growth Ability to cause death Ability to spread
A nurse is preparing a presentation about human immunodeficiency virus (HIV) for a local community group. What would the nurse include in the presentation about HIV transmission? Select all that apply.
The risk of acquiring HIV through the transfusion of blood products is almost nonexistent. The amount of HIV contained in body fluids on exposure is associated with the risk for infection. HIV can be found in seminal fluid, vaginal secretions, and breast milk. Sharing of infected equipment used to inject drugs increases the risk for infection.
A client is diagnosed with a delusional disorder. While providing care to the client, the nurse assesses the client's delusions. Which would be least appropriate for the nurse to do?
Try to change the client's delusional belief
A patient with end-stage renal failure has made the decision to be put on the kidney transplant waiting list and now eagerly anticipates the possibility of eventually being matched with a donor. How can the patient maximize his chances of being able to undergo a transplant when a kidney becomes available?
Trying to stay free of infections
The nurse performs acute intermittent peritoneal dialysis (PD) on a client who is experiencing uremic signs and symptoms. The peritoneal fluid is not draining as expected. What is the best response by the nurse?
Turn the client from side to side.
A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. IV fluid is being infused at 150 mL/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?
Urine output of 250 ml/24 hours
A client is receiving radiation therapy and asks the nurse about oral hygiene. What teaching specific to the client's situation should the nurse include?
Use a soft toothbrush and allow it to air dry before storing.
A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?
Use incentive spirometry every hour.
During assessment, a patient with chronic liver dysfunction tells the nurse that he is experiencing spontaneous episodes of bleeding and has noticed increased areas of bruising on his chest and arms. The nurse suspects a deficiency in:
Vitamin K
A nurse is discussing cardiac hemodynamics with a client and explains the concept of afterload. What are other preexisting medical conditions to discuss that may increase afterload? Select all that apply
aging hypertension aortic valve stenosis
At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-Medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer:
albuterol (Proventil).
The nurse is beginning discharge teaching with a client diagnosed with a myocardial infarction (MI). The nurse will include teaching on what medications? Select all that apply.
atorvastatin enalapril aspirin
A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for:
fatigue and weakness.
A nurse is assessing a client with heart failure. What breath sound is commonly auscultated in clients with heart failure?
fine crackles.
A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction?
"Increase your carbohydrate intake."
A nurse is teaching the client about use of the pictured item with a metered-dose inhaler (MDI). What instructions should the nurse include in the teaching? Select all that apply.
Take a slow, deep inhalation from the device. Activate the MDI once. The device may increase delivery of the MDI medication.
A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?
Take ordered medications as scheduled.
The nurse is caring for a patient receiving hemodialysis treatments and who has an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient?
Taking a blood pressure reading on the affected arm can cause clotting of the fistula.
A nurse is caring for a client admitted with acute pancreatitis. Which nursing action is most appropriate for a client with this diagnosis?
Withholding all oral intake, as ordered, to decrease pancreatic secretions
A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. This change occurred because:
the airways are so swollen that no air can get through.
A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when he:
uses the sternocleidomastoid muscles.
The most accurate indicator of fluid loss or gain in an acutely ill client is:
weight.
Following surgery for adenocarcinoma, the client learns the tumor stage is T3,N1,M0. What treatment mode should the nurse anticipate?
Adjuvant therapy is likely.
What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention?
Albumin infusion
A client with a history of chronic renal failure receives hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan?
Assess the AV fistula for a bruit and thrill.
A client with acquired immune deficiency syndrome (AIDS) comes to the clinic reporting difficulty swallowing. The client says, "It hurts so much when I swallow." Inspection reveals creamy white patches in the client's mouth. What will the nurse suspect?
Candidiasis
A public health nurse has identified that a community's HIV education strategy does not address the educational needs of older adults, even though this population is vulnerable to infection with the virus. Which of the following factors puts older adults at risk of HIV infection? Select all that apply.
Rates of condom use are low among older adults. Overall immune function is diminished as a result of age-related changes. Many older adults are not aware of the risk of HIV infection.
A nurse practitioner treating a patient who is diagnosed with hepatitis A should provide health care information. Which of the following statements are correct for this disorder? Select all that apply.
There is a 70% chance that jaundice will occur. Transmission of the virus is possible with oral-anal contact during sex. Typically there is a spontaneous recovery.
