practice qs

A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? "I can resume my daily aspirin therapy." "I will contact my provider if my eye feels itchy." "I will bend at my knees when picking an object up off the floor." "It's okay for me to pick up my grandchild who weighs 20 pounds."

"I will bend at my knees when picking an object up off the floor."

A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations 5) Kussmaul Respirations

1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations

A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? 1) Shivering 2) Infection 3) Burns 4) Hypervolemia

1) Shivering

A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? 1)Cover the client's wound with a moist, sterile dressing. 2)Have the client lie supine with knees flexed. 3)Check the client's vital signs. 4)Inform the client about the need to return to surgery.

1)Cover the client's wound with a moist, sterile dressing.

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? 1) Rub the client's feet briskly for several minutes. 2) Obtain a pair of slipper socks for the client. 3) Increase the client's oral fluid intake. 4) Place a moist heating pad under the client's feet.

2) Obtain a pair of slipper socks for the client.

A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make? 1- "the pain results from lying in one position too long during surgery" 2- "the pain will dissipate if you ambulate frequently" 3- "the pain occurs as a residual pain from cholecystitis" 4- "The pain is caused from the nitrous dioxide injected into the abdomen"

2- "the pain will dissipate if you ambulate frequently"

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? 1) Rest in a supine position. 2) Consume a low-protein diet. 3)Breathe in through her nose and out through pursed lips. 4) Limit fluid intake throughout the day

3)Breathe in through her nose and out through pursed lips.

A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report?

Abnormal vaginal bleeding

A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3 . Which of the following food items brought by the family should the nurse prohibit from being given to the client? a) Fresh fruits and vegetables b) Cooked meats c) Canned soups d) Raw sushi

Fresh fruit basket

A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching?

"I will take a tub bath instead of a shower."

A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

"I will wear stockings with elastic tops."

A nurse is caring for a client who is going to have a bone marrow biopsy under conscious sedation. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? "The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible." "Relax, you'll be asleep for most of the procedure and you won't remember a thing! "I will call your doctor and tell him you still have questions about the procedure "I can understand because you must be very worried about what the biopsy will show."

"The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible."

A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? A. Monitor intake and output hourly B. Check for decreased BUN C. Monitor Serum ALT D. Assess site for bleeding

A. Monitor intake and output hourly

A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? A. Report decreased sensation of the affected extremity to the provider. B. Keep the joint in a flexed position. C. Apply moist heat to the affected area. D. Expect pain and swelling in the calf postoperatively

A. Report decreased sensation of the affected extremity to the provider.

.A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? A. Measure abdominal girth daily B. Maintain the client in Fowler's position. C. Moisten the client's lips with lemon-glycerin swabs. D. Use sterile water to irrigate the nasogastric tube.

A. Measure abdominal girth daily

A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? A. "I should avoid injecting insulin into my thigh if I am going to go running." B. "I will carry a complex carbohydrate snack with me when I exercise." C. "I should exercise first thing in the morning before eating breakfast." D. "I will increase the intensity of my exercise routine if my urine is positive for ketones."

A. "I should avoid injecting insulin into my thigh if I am going to go running."

A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? A. Airway obstruction B. Hypervolemia C. Tachypnea D. Tachycardia

A. Airway obstruction

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? A. Check the client's vital signs. B. Request a dietitian consult. C. Suggest that the client rests before eating the meal. D. Request an order for an antiemetic.

A. Check the client's vital signs.

A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? A. Decreased color perception B. Loss of peripheral vision C. Bright flashes of light D. Eyestrain

A. Decreased color perception

A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) A. Encourage fluid intake. B. Monitor the puncture site for hematoma. C. Insert a urinary catheter. D. Elevate the client's head of bed. E. Apply a cervical collar to the client.

A. Encourage fluid intake B. Monitor the puncture site for hematoma.

A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? A. Take this medication between meals. B. Limit intake of Vitamin C while taking this medication. C. Take this medication with milk. D. Limit intake of whole grains while taking this medication.

A. Take this medication between meals.

A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? Abdomen is distended Chest tube drainage of 70 mL in the last hour Subcutaneous emphysema is noted to the left chest wall Pain level of 6 on a 0 to 10 scale

Abdomen is distended

A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? Altered level of consciousness Oral temperature of 37.7° C (100° C) Muscle spasms Headache

Altered level of consciousness

A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take? A.Instruct the client to place their chin to their chest when swallowing B. Add thickener to foods C. Offer the client sick foods such as peanut butter D.Place food on the affected side of the cline't mouth

B. Add thickener to foods

A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? A. Protruding Eyes B. Hardened SKin C. Dyspnea D. SpO2 89%

B. Hardened SKin

A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take? A) Check the patency of the drain every 12H. B) Clamp the drain while the client is ambulating. C) Cleanse the drain plug with alcohol after emptying. D) Secure the drain to the client's bed sheet.

C) Cleanse the drain plug with alcohol after emptying.

A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? A. "A flexible tube is introduced through the nose during the procedure." B. "During the procedure you are in a sitting position." C. "You will remain NPO for 8 hours before the procedure." D. "You will be awake while the procedure is performed."

C. "You will remain NPO for 8 hours before the procedure."

A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) A. Purple striations B. Tremors C. Buffalo hump D. Obese extremities E. Moon face

C. Buffalo hump A. Purple striations E. Moon face

A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take A. Position the weights on the traction so they are touching the head of the client's bed C. Ensure the client's weights are hanging freely from the bed. Encourage isometric exercises every 8 hr D. Administer pain medication to the client before performing pin care

C. Ensure the client's weights are hanging freely from the bed.

A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? A. Pain management measures B. Providing oral hygiene C. Preventing aspiration D. Checking pressure areas for redness

C. Preventing aspiration

A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Continue to monitor the client as this is an expected finding. B. Add more water to the suction control chamber of the drainage system. C. Verify that the suction regulator is on and check the tubing for leaks. D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.

C. Verify that the suction regulator is on and check the tubing for leaks.

A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? A. Apply topical antifungal agents. B. Apply fresh ice packs every 4 hrs. C. Wash daily w/ an antibacterial soap. D. Keep draining lesions uncovered to air dry.

C. Wash daily w/ an antibacterial soap.

A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? A. Calmly ask the client if he would like to listen to some music. B. Turn the water on and ask the client to test the temperature. C. Firmly tell the client that good hygiene is important. D. Obtain assistance to place mitten restraints on the client.

Calmly ask the client if he would like to listen to some music.

A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?

Change the nasal drip pad as needed.

A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? A. Administer antispasmodic medications. B. Notify the provider. C. Offer oral fluids. D. Determine the patency of the tubing.

D. Determine the patency of the tubing.

A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? A. Treat nasal rhinitis with an over-the-counter antihistamine. B. If a medication dose is missed, wait until the next scheduled dose to take the medication. C. Expect diaphoresis as a side effect of the neostigmine. D. Take the medication 45 minutes before eating.

D. Take the medication 45 minutes before eating.

A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? A. Empty the pouch immediately after meals. B. Change the entire appliance once a day. C. Limit fluid intake. D. Avoid medications in capsule or enteric form.

D. Avoid medications in capsule or enteric form.

A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first?

Feel for a carotid pulse.

A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following?

Granulation tissue

A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? Hypercapnia Tachycardia Hypervolemia Hypotension

Hypotension

A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of the following manifestations should the nurse monitor?

Hypotension

A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan?

Maintain abduction of the right hip.

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? Aura phase Presence of automatisms Postictal phase Presence of absence seizures

Postictal phase

A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? Weight loss of 3% of total body weight. Blood glucose 150 mg/dL Potassium 2.5 mEq/L Urine specific gravity 1.035

Potassium 2.5 mEq/L

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

Prevent bladder distention.

A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? Provide humidified oxygen. Perform chest physiotherapy prior to suctioning. Prelubricate the suction catheter tip with sterile saline when suctioning the airway. Hyperventilate the client with 100% oxygen before suctioning the airway.

Provide humidified oxygen.

A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan?

Re-establish communication.

A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include:pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/LWhich of the following interpretations of the ABG values should the nurse make

Respiratory acidosis

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?

Take temperature once a day

A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take?

Tell the client to remain in the bathroom after toileting and obtain a wheelchair

A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?

Thick, red-colored urine

A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?

To prevent blood clotting

A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? a) Gradual loss of peripheral vision b) Blurred central vision c) Flashes of light d) Severe eye pain

a) Gradual loss of peripheral vision

A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? a. Large incisions will be made in the eschar to improve circulation b. I can call the doctor back here if you want me to c. A piece of skin will be removed and grafted over the burned aread. d. Dead tissue will be surgically removed

a. Large incisions will be made in the eschar to improve circulation

A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? 1) Elevated blood pH levels b) Increased heart rate and blood pressure c) Hyperventilation d) Confusion and decreased level of consciousness

c) Hyperventilation

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

purulent

A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?

test for glucose