PN Med Surg Prac. 2017 A

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 immunization every 10 years."* The nurse should remind the client to have a pneumococcal immunization at age *65 and every 10 years* thereafter to protect her from acquiring pneumonia. *Wrong: "You should have a screening for glaucoma every 5 years."* The nurse should remind the client to have a screening for glaucoma every *2 to 3 years* along with an annual visual accuity exam. *Wrong: "You should have a physical examination every other year."* The nurse should remind the client to have a physical examination *every year.* *Wrong: "You should have your hearing checked every 2 years."* The nurse should remind the client to have her hearing checked *every year*.

A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate?

*Bradycardia* The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused by a decrease in the client's metabolic rate. *Wrong: Weight loss* The nurse should identify that weight loss is a manifestation of *hyperthyroidism* caused by an increase in the client's metabolic rate. *Wrong: Blurred vision* The nurse should identify that blurred vision is a manifestation of *hyperthyroidism.* *Wrong: Insomnia* The nurse should identify that insomnia is a manifestation of *hyperthyroidism* that is caused by an increase in the client's metabolic rate.

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.* 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 participating in a health fair for older adult clients. Which of the following immunizations should the nurse recommend for this age group?

*Herpes zoster*: The nurse should recommend the herpes zoster immunization for adults 60 years of age and older.

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 inflamed joints

A nurse is reinforcing teaching with the family of a client with 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 *change when spikes or at least once per week to prevent skin irritation

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

Decreased potassium

A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has a loss of appetite because she has sores in her mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make?

Eat several, small portion meals daily.

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 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 has a new prescription for nystatin suspension for oral candidiasis following interventions should the nurse include in the plan?

Instruct the client to swish the medication in her mouth

A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following?

Intra-abdominal bleeding

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 contin passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care?

Keep a sheepskin pad between the clients extremity and the CPM

A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 he ago. Which of the following interventions should the nurse identify as the priority?

Keep the client in a side lying position *The greatest risk to the client following a stroke is aspiration. Laying on side will allow secretions to drain out of the mouth.

A nurse observes a client who is lying in bed 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 assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first?

Maintain the clients body alignment

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

Recommend a referral for a speech language pathologist. 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 recommend a referral for a 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.

Following a blood draw precedure for a fasting blood sugar (FBS) test, a client tells the nurse, "I'm glad they took my blood because i'm really hungry. All I've had since midnight is water and some juice." Which of the following actions should the nurse take?

Reschedule the FBS test for early the next morning

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 reports intense itching. Which of the following actions should the nurse take first?

Stop the medication infusion

A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider?

ceftriaxone