PN Adult Medical Surgical Online Practice 2020 A with NGN

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. [The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration.]

A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use?

Mask Rationale: 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 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 information should the nurse include in the teaching?

Mogs sx is a horizontal shaving of thin layers of the tumor

The nurse is reviewing the client's diagnostic results. Which of the following findings require follow up? Select all that apply.

PaCO2 WBC count Chest x-ray Oxygen saturation BUN

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

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

A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first?

Stop the medication infusion. Rationale: 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. -------------------- The nurse should notify the charge nurse about what has occurred. However, there is another action the nurse should take first. The nurse should administer a PRN dose of diphenhydramine to keep the allergic reaction from worsening. However, there is another action the nurse should take first. The nurse should follow facility policy when reporting an adverse reaction. However, there is another action the nurse should take first.

Drag words from the choices below to fill in each blank in the following sentence.

Respiratory failure and hypovolemia

A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. After stopping the infusion, which of the following actions should the nurse take next?

Take the client's vital signs. Rationale: 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.

The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention.

Temperature WBC Potassium • Temperature is correct. The nurse should identify that the client continues to have a fever as a result of the body's immune system fighting the infection. Therefore, this finding requires nursing intervention. • WBC count is correct. The nurse should identify that the client's WBC count remains elevated, which indicates an infection. Therefore, this finding requires nursing intervention. • Heart rate is incorrect. The nurse should identify the client's heart rate is within the expected reference range. Therefore, this finding does not require nursing intervention. • Potassium level is correct. The nurse should identify that the client's potassium level is elevated, which places them at risk for cardiac dysrhythmias. Therefore, this finding requires nursing intervention. Oxygen saturation is incorrect. The nurse should identify the client's oxygen saturation has improved and is within the expected reference range. Therefore, this finding does not require nursing intervention.

Drag 1 condition and 1 client finding to fill in each blank in the following sentence

The client is experiencing manifestations of pancreatitis as evidenced by amylase and lipase

A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. 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. (Nurse should identify that a client who is in pain will not be able to concentrate which can interfere with his ability to learn.) -Nurse should identify that asking questions indicate active listening by the client and enhances learning. - Nurse should identify that clients learn . in different ways. Using multiple methods of teaching, including hands on practice and providing written materials enhances learning. - Nurse should identify that family members who are actively engaged in the teaching session and ask questions can enhance learning.

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The nurse is caring for the client who has manifestations of peritonitis therefore, the priority finding for the nurse to report is laboratory values Peritonitis is correct. The client has manifestations of peritonitis, including rigid abdomen and elevated WBC count and ESR. Peritonitis is an inflammation and infection of the abdominal cavit that can occur when bacteria enter the peritoneum through a perforation in the bowel as a complication of Crohn's disease. Laboratory values is correct. The nurse should identify that the client's laboratory values is the priority to report when using the urgent vs. nonurgent priority framework. An elevated WBC count and a high neutrophil count indicates an infection, which is a manifestation of peritonitis.

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 is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect?

compartment syndrome

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.

The nurse is reinforcing discharge teaching with the client. Which of the following client statements indicates an understanding of the teaching? Select all that apply.

• "I should schedule several rest periods throughout the day" • "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit".

A nurse is prioritizing care for the client. Complete the following sentence by using the lists of options.

• At 1000, the nurse should first address the client's oxygen saturation , • followed by the client's heart rate

The nurse is collecting data on the client. For each client finding, click to specify if the finding is consistent with appendicitis, diverticular disease, or Crohn's disease. Each finding may support more than 1 disease process.

• Blood in the stool - Diverticular disease & Crohn's disease • Pain in the right lower quadrant - appendicitis & Crohn's disease • Mucus in the stool - Crohn's disease • Nausea - appendicitis, diverticular disease, & Crohn's disease

The nurse is reviewing the client's medical record. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again.

• Client is short of breath and has a productive cough with yellow mucus • States, "I could barely breathe when I got up this morning and I had a throbbing headache" • Client is diaphoretic • Crackles heard in posterior lung

A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.)

"I never forget to rinse my mouth after using my budesonide inhaler." "Between office visits, I keep a record of how many times I use my albuterol inhaler." "I use my albuterol inhaler before I go swimming."

A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching?

"This type of insulin be given at the same time every day"

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?

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

"You feel like you want to discontinue treatment?"

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 immunizations every 10 years."

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.* *Correct: Thickened liquids are easier for the client to swallow and can prevent aspiration. *Wrong: Provide small, frequent meals:* Providing small, frequent meals can improve the client's nutritional intake, but it does not decrease the risk for aspiration. *Wrong: Tell the client to extend his neck when swallowing.* The client should tilt his neck forward while swallowing to decrease the risk for aspiration. *Wrong: Provide mouth care before meals.* Mouth care can enhance the client's sense of taste, but it does not decrease the risk for aspiration.

A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an IN of 4. Available is phytonadione 10 mg/mL. How many ml should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.7

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 medication?

Abdominal cramps. Rationale: 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. ------------------ Polyuria is an adverse effect of furosemide. Long-term and high-dose use of acarbose can cause liver dysfunction, not renal insufficiency. Insomnia is an adverse effect of methylphenidate.

Complete the following sentence by using the lists of options.

After reviewing the findings in the client's medical record, the nurse should first address the client's (1) abdominal distention, followed by the client's (2) acute pain

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 for aspiration?

Allow 30 min of rest before meals

A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care?

Apply a mask on the client if transport is needed.

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 inamed joints.

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

Avoid bending your hips more than 90 degrees. ( to prevent dislocation of the replacement hip). - Nurse should instruct client to wait 90 days before crossing legs. Crossing legs early int heh postoperative period can result in dislocation of the replacement hip. -Nurse should inform the client that she ay lie on her operative side with a pillow between her legs. This will not injure the suture site or cause dislocation of the replacement hip. - Nurse should instruct the client to sleep on a firm mattress to avoid potential dislocation of the replacement hip.

A nurse is reinforcing teaching with the client. Which of the following instructions should the nurse include? Select all that apply.

Avoid drinking fluids with meals. Eat several small meals per day. Consume high-protein snacks.

A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching?

Avoid eating red meat for 3 days prior to the test.

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.

The nurse is collecting data on the client. For each client finding, click to specify if the finding is consistent with appendicitis, diverticular disease, or Crohn's disease. Each finding may support more than 1 disease process.

Blood in the stool - Diverticular disease

A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Ceftriaxone In exhibit 2 it says the patient is allergies: "penicillin reaction severe".

A nurse is reinforcing 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. Rationale: 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. -------------------- The nurse should instruct the caregiver to clean the pin sites every day to decrease the risk for infection. The nurse should instruct the caregiver to never lift or reposition the client by pulling on the halo ring, which can cause further cervical injury. The nurse should instruct the caregiver to call a provider if the pins or traction bar is loose. The pin sites or traction bar supports should not be manipulated in any way because it could cause injury to the client.

A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Check the IV site. Stop the infusion. Withdraw the IV catheter. Elevate the affected arm. Notify the charge nurse.

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 history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client?

Combination oral contraceptives Rationale: 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. --------------------------- The nurse should identify that the use of an intrauterine device requires the client to check the placement monthly and is not contraindicated for this client. The nurse should identify that the use of latex condoms is contraindicated for clients, or their partners, who are allergic to latex. However, it is not contraindicated for this client. The nurse should identify that prolonged use of a contraceptive sponge can increase the risk for toxic shock syndrome. However, it is not contraindicated for this client.

The nurse is assisting with the plan of care for the client. For each potential provider prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Cough and deep breathe every 2 hr is anticipated Obtain a sputum culture and sensitivity is anticipated Titrate oxygen to keep oxygen saturation greater than 90% is anticipated. Place client on a 1,500 mL fluid restriction is contraindicated Administer acetaminophen 500 mg PO every 6 hr PRN is anticipated. Administer famotidine 40 mg PO daily is nonessential.

A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure?

Creatinine 1.9 mg/dL Normal range is 0.7 to 1.3 Therefore the it's high and should be reported the the provider

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?

Dangle the extremities off the side of the bed.

A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include?

Dispose of radiation implants in a lead container: Rationale: Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation implants in a lead container in accordance with facility protocol. ------------------------------ Pregnant women and children should not be allowed to visit a client who is receiving internal radiation therapy because of the risk for exposure to radiation emissions. The nurse should use forceps to pick up a radiation implant if it becomes dislodged. The nurse should limit time spent in the client's room to 30 min during an 8 hr shift.

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

Dropdown 1 Peritonitis is correct. The client has manifestations of peritonitis, including rigid abdomen and elevated WBC count and ESR. Peritonitis is an inflammation and infection of the abdominal cavity that can occur when bacteria enter the peritoneum through a perforation in the bowel as a complication of Crohn's disease. Pericarditis, peptic ulcer disease, hepatitis, and gastroenteritis are incorrect. Pericarditis is an inflammation of the sac that surrounds the heart. The client's clinical findings are not consistent with pericarditis. Peptic ulcer disease results when the gastrointestinal mucosa becomes impaired and no longer provides protection from the effects of acid and pepsin. Hepatitis is inflammation of the liver. The client's clinical findings are not consistent with hepatitis. Gastroenteritis is inflammation of the mucous membranes of the stomach and intestinal tract, caused by food or water contamination. The client's clinical findings are not consistent with gastroenteritis. Dropdown 2 Laboratory values is correct. The nurse should identify that the client's laboratory values is the priority to report when using the urgent vs. nonurgent priority framework. An elevated WBC count and a high neutrophil count indicates an infection, which is a manifestation of peritonitis. Bowel sounds, diarrhea, small amount of blood in the stool, and weight loss trend are incorrect. The nurse should report hypoactive bowel sounds, diarrhea, small amount of blood in the stool, and the weight loss trend because the client is at risk for impaired nutrition and electrolyte imbalance. However, there is another finding that is the priority.

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 from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority?

Dysrhythmia RAT: 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 sores in their mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make?

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?

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?

Encourage the client to complete ADLs.

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?

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 a client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss?

Encourage weight-bearing exercises. r-Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis.

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?

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 reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective?

Hbg 11 g/dL

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 collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT?

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

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Hypovolemia Insert a large gauge IV Initiate a fluid challenge Urine output blood pressure

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?

I understand that testicular cancer is painless. ( Clients should report a lump that is NOT painful bc testicular cancer is typically painless). - Perform a testicular self examination after a WARM shower - Perform testicular self exam MONTHLY - Clients should report pea- sized lump in the testes to the provider.

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

Implement recommendation from the speech language pathologist. Rationale: 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. Client

A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include?

Incontinence of the bowel and bladder

A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following instructions should the nurse include in the teaching?

Increase fiber-rich foods. Rationale: 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. --------------- Instruct the client to increase their fluid intake to 2,000 mL/day to maintain soft stools. Instruct the client to increase activity to stimulate the evacuation of stool.

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

Initiate oxygen at 4L/min via nasal cannula. Rationale: 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. --------------------------- The nurse should collect a sputum culture to identify the organism causing the client's infection. Antimicrobial sensitivities are obtained from the sputum culture to guide the provider in prescribing antibiotics. However, there is another prescription the nurse should implement first. The nurse should administer antibiotics to treat the infection. A broad spectrum antibiotic, such as ceftriaxone, is administered when sepsis is suspected because it treats both gram-positive and gram-negative bacteria. After the results of the blood and sputum cultures are obtained, the provider will often change to a more specific antibiotic. However, there is another prescription the nurse should implement first. The nurse should obtain blood cultures to identify the organism causing the client's infection. Antimicrobial sensitivities obtained from the blood cultures will guide the provider in prescribing treatment. However, there is another prescription the nurse should implement first.

Which of the following actions should the nurse take? Select all that apply.

Instruct the client to splint their abdomen with a pillow when coughing plan to ambulate the client as soon as possible report the client's urinary output to the charge nurse monitor the client's pain level

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.

A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma?

Irregular borders

A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care?

Keep a sheepskin pad between the client's extremity and the CPM machine.

A nurse is contributing to the plan of care for a client who was 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. RAT: 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 caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown?

Keep the skin dry and free of perspiration. RAT: The nurse should not leave moisture on the skin for prolonged periods of time because it can cause skin breakdown.

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

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

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 nurse's instructions?

"I don't cross my legs anymore." RAT: Clients who have peripheral vascular disease should not cross their legs because it can impede circulation.

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

"Consume foods low in sodium."

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?

"Do not allow visitors to smoke cigarettes in your home." Rationale: The nurse should inform the client that cigarette smoke is a common allergen that can increase the risk for triggering an asthma attack. Therefore, the client should not allow anyone to smoke cigarettes in their home. -------------------------- The nurse should inform the client that carpet can hold mites and dust, which increases the risk for triggering an asthma attack. The nurse should inform the client that breathing cold air can cause bronchial constriction, which increases the risk for triggering an asthma attack. The nurse should inform the client that opening their windows during spring can increase their exposure to environmental allergens, which increases the risk for triggering an asthma attack.

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."

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

A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care?

Administer an antiemetic to the client

The nurse is assisting with the care of the client who is preoperative for an exploratory laparotomy. Select the 4 actions the nurse should take.

Administer phenytoin with a sip of water on the day of surgery. Assist with the administration of gentamicin 100 mg IV. Assist with the administration of dextrose 5% in lactated Ringer's. Contact the wound, ostomy, and continence nurse.

A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication?

Decreased potassium RAT: The nurse should notify the provider immediately about a decreased potassium level because potassium is lost when a diuretic, such as furosemide, is administered, which can cause hypokalemia. The nurse should expect a client who has heart failure to have a decreased urine output and does not need to report this finding to the provider before administering the medication. Furosemide is a diuretic, which should cause an increase in urine output for a client who has heart failure.The nurse should expect a client who has heart failure to have an elevated blood pressure and does not need to report this finding to the provider before administering the medication. Furosemide is a diuretic that should help to lower the client's blood pressure. The nurse should report a decreased sodium level to the provider before administering the medication because furosemide can cause hyponatremia.

A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect?

Decreased shortness of breath. Rationale: The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion. ------------------ The nurse should expect the client's weight to decrease because of the increased excretion of fluid that is caused by improved cardiac output. The nurse should expect the client's heart rate to decrease because digoxin decreases the client's sympathetic nerve tone, which slows the heart rate. The nurse should expect the client to have an increase in urinary output because digoxin improves cardiac output and increases the client's renal blood flow through the kidneys, which results in an increased excretion of urine.

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 surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority?

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 contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (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. Rationale: 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.

The nurse is contributing to the plan of care for the client who has peritonitis and Crohn's disease. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the client.

Obtain blood cultures - indicated obtain the client's vital signs every 15 min - indicated Administer a hypotonic IV solution - contraindicated insert a nasogastric tube - indicated

A nurse is caring for a client 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?

Perform pin site care daily. Rationale: 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. --------------------------- The nurse should ensure the client has an overbed trapeze to aid in lifting the upper body off the bed when necessary and to help prevent skin breakdown of the heels and elbows with client repositioning. The nurse should identify that balanced suspension skeletal traction is managed through the use of pins, pulleys, weights, and frames and that the client does not wear a boot. The nurse should ensure the weights hang freely at all times.

A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration?

Pinch the NG tube. Rationale: The nurse should pinch the NG tube to prevent secretions from draining into the client's throat, which can cause aspiration. ---------------------- The nurse should instill 50 mL of air through the NG tube to remove mucus and gastric secretions from the tube and to prevent aspiration of these secretions. The nurse should place the client in a sitting position to prevent the risk for aspiration. The nurse should identify that irrigating the NG tube before removal can put the client at risk for aspiration and should be avoided.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Reduce the temperature in the clients room. Limit visitors Hyperthyroidism Increased temperature Weight daily

A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Remind the client to avoid watching their feet when walking.

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors?

Visitors must don a gown and gloves before entering client's room. ( This patient will be on a client on contact isolation precautions. Contact precautions requires visitors to put on a gown and gloves prior to entering the client's room to prevent MRSA from spreading) - Nurse should identify visitors of clients who are on airborne or droplet precautions should wear a mask within 3 feet of the client. -MRSA does not spread through the respiratory tract and does not need airborne or droplet precaution. -NO FRESH FLOWERS for patient on neutropenic precaution .

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 manifestations indicate which of the following complications of IV therapy?

Thrombophlebitis Rationale: The nurse should identify pain, warmth, and a red streak up the arm as indications of thrombophlebitis. --------------------- swelling and cool skin at the IV site as indications of infiltration. swelling and bruising as indications of a hematoma that can develop by not holding enough pressure after discontinuing the IV. cramping at or above the insertion site and numbness as indications of venous spasms.

A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan?

Use simple verbal cues when directing tasks. The 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 client who had a left hemisphere stroke will display slow movement and cautious behavior. A client who has had a right hemisphere stroke, in contrast, will exhibit impulsive and unsafe behavior. A client who had a left hemisphere stroke might have deficits, such as impaired vision on the right side of the body. The nurse should approach the client from the unaffected, or left side, of their body. The nurse should place the client in high-Fowler's position when eating, drinking, or taking medications to facilitate swallowing. If the client displays manifestations of dysphagia, the nurse should consult the provider for further evaluation of the client.

The nurse is reviewin the client's medical record from Day 5. Click to highlight the findings that indicate the client is improving. To deselect a finding, click on the finding again.

• Heart rate is 72/min is correct. The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. Respiratory rate is 20/min is correct. The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. Blood pressure is 128/56 mm Hg is correct. The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. • Oxygen saturation is 95% on room air is correct. The client's oxygen saturation is within the expected reference range and no longer requires supplemental oxygen. Therefore, this finding indicates the client's pulmonary status is improving.