Prep u

• The client has a right to refuse the transfusion.

A 18-year-old client presents to the emergency department with a severe open fracture of the lower extremity. The health care provider tells the client that the client will need a blood transfusion. The client refuses, despite the advise of the health care provider. What does the nurse understand is the legal implication of the scenario? • The client has a right to refuse the transfusion. • The health care provider may first call the client's parents if the client refuses. • The client can only refuse the transfusion if the consent form has not been signed. • The health care provider may ask for a court order if the client refuses.

• Peaked T waves

A client admitted to the telemetry unit has a serum potassium level of 6.6 mEq/L. Which electrocardiographic (ECG) characteristic is commonly associated with this laboratory finding? • Occasional U waves • Peaked T waves • Flattened P waves • Prolonged QT interval

Hematological

A client complains of extreme fatigue. Which system should the nurse suspect is most likely affected? • Neurological • Hematological • Integumentary • Respiratory

Control ventricular heart rate

A client converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and diltiazem are given. The nurse caring for the client understands that the main goal of treatment is what? • Decrease SA node conduction • Control ventricular heart rate • Improve oxygenation • Maintain anticoagulation

• Stage 3

A client has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the client's chronic kidney disease is at what stage? • Stage 1 • Stage 2 • Stage 3 • Stage 4

• moist, gurgling respirations

A client has been admitted to the cardiac step-down unit with acute pulmonary edema. Which symptoms would the nurse expect to find during assessment? • moist, gurgling respirations • drowsiness, numbness • increased cardiac output • hypertension

• Insertion of an NG tube for decompression

A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? • Administration of antiemetics • Insertion of an NG tube for decompression • Infusion of hypotonic IV solution • Administration of proton pump inhibitors as prescribed

• third-spacing

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting? • third-spacing • pitting edema • anasarca • hypovolemia

• Foods • Medications • Insect stings

A client has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the client's condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply. • Foods • Medications • Insect stings • Autoimmunity • Environmental pollutants

• All options are correct.

A client has been burned significantly in a workplace accident. Which conditions create the need for intensive care by specifically trained personnel? • All options are correct. • fluid shift • fluid loss • hypotension

• Hospice care

A client has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the client is most likely to require which of the following? • Inpatient rehabilitation • Rehabilitation in the home setting • Intensive physical therapy • Hospice care

• Decrease sodium intake

A client has just been diagnosed with prehypertension. What would the nurse instruct this client to do to restore his blood pressure below hypertensive levels? Increase iodine intake Decrease sodium intake Increase fluid intake Avoid over-the-counter decongestants

• Bleeding at the implantation site

A client has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this client? • Chest pain • Bleeding at the implantation site • Malignant hyperthermia • Bradycardia

Hypocalcemia

A client has returned to the floor after having a thyroidectomy for thyroid cancer. What laboratory finding may be an early indication of parathyroid gland injury or removal? • Hyponatremia • Hypophosphatemia • Hypocalcemia • Hypokalemia

• Respiratory dysfunction

A client has undergone surgery for a spinal cord tumor that was located in cervical area. The nurse would be especially alert for which of the following? • Hemorrhage • Bowel incontinence • Respiratory dysfunction • Skin breakdown

Lack of erythropoietin

A client in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which of the following reasons? • Preparation for likely nephrectomy • Increases the effectiveness of dialysis • Hypervolemia • Lack of erythropoietin

• Assess the client's breath odor

A client is admitted to the health care center with abdominal pain, nausea, and vomiting. The medical reports indicate a history of type 1 diabetes. The nurse suspects the client's symptoms to be those of diabetic ketoacidosis (DKA). Which action will help the nurse confirm the diagnosis? • Assess the client's ability to take a deep breath • Assess the client's ability to move all extremities • Assess the client's breath odor • Assess for excessive sweating

• Relieving abdominal pain

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? • Relieving abdominal pain • Preventing fluid volume overload • Maintaining adequate nutritional status • Teaching about the disease and its treatment

Regular

A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously? • Glargine • Regular • NPH • Lente

• Ineffective breathing pattern

A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority? • Fatigue • Excess fluid volume • Ineffective breathing pattern • Imbalanced nutrition: Less than body requirements

• Start IV fluids with a normal saline solution bolus followed by a maintenance dose.

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? • Encourage oral fluids. • Administer furosemide (Lasix) 20 mg IV • Start hemodialysis after a temporary access is obtained. • Start IV fluids with a normal saline solution bolus followed by a maintenance dose.

• Airway management

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? • Pain • Fluid balance • Anxiety and fear • Airway management

• Type O

A client is in the hospital with a bleeding gastric ulcer and requires a blood transfusion. He has been typed and crossmatched for 2 units of packed red blood cells and found to have type O blood. What type of blood will the nurse administer to this client? • Type A • Type B • Type AB • Type O

• Obtains results of a swallow study • Provides thick liquids

A client is postoperative for a partial laryngectomy following a diagnosed malignancy. The client is to start oral feedings. The nurse does the following interventions: (Select all that apply.) • Facilitates privacy while eating • Obtains results of a swallow study • Provides thick liquids • Orders a regular diet tray

24

A client is receiving intravenous heparin to prevent blood clots. The order is for heparin 1,200 units per hour. The pharmacy sends 25,000 units of heparin in 500 mL of D5W. At how many milliliters per hour will the nurse infuse this solution? Record your answer using a whole number.

0.8

A client is receiving morphine to relieve chest pain. The order is for 4 mg IV now. The pharmacy supplies morphine sulfate at 5 mg per mL. How many mL will the nurse give the client? Enter the correct number ONLY.

c. Enzyme-linked immunosorbent assay

A client is suspected of having an immune system disorder. The physician wants to perform a diagnostic test to confirm the diagnosis. What test might the physician order? • T-and C-cell assays • Complete chemistry panel • Enzyme-linked immunosorbent assay • Plasmapherisis

• Enzyme-linked immunosorbent assay

A client is suspected of having an immune system disorder. The physician wants to perform a diagnostic test to confirm the diagnosis. What test might the physician order? • T-and C-cell assays • Complete chemistry panel • Enzyme-linked immunosorbent assay • Plasmapherisis

• Discontinue the remainder of the PRBC transfusion and inform the health care provider.

A client on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action? • Apply an icepack to the blood that remains to be infused. • Discontinue the remainder of the PRBC transfusion and inform the health care provider. • Disconnect the bag of PRBCs, cool for 30 minutes and then administer. • Administer the remaining PRBCs by the IV direct (IV push) route.

• 36%.

A client presents to the emergency department following a burn injury. The client has burns to the anterior chest and entire left leg. Using the rule of nines, the nurse documents the total body surface area percentage as • 36%. • 27%. • 18%. • 9%.

• Avoiding using soap on the irradiated areas

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan? • Avoiding using soap on the irradiated areas • Applying talcum powder to the irradiated areas daily after bathing • Wearing a lead apron during direct contact with the client • Removing thoracic skin markings after each radiation treatment

• Keep the client in semi-Fowler position for 1 hour after feedings

A client receiving tube feedings is experiencing diarrhea. The nurse and the health care provider suspects that the client is experiencing dumping syndrome. What intervention is mostappropriate? • Stop the tube feed and aspirate stomach contents. • Increase the hourly feed rate so it finishes earlier. • Keep the client in semi-Fowler position for 1 hour after feedings • Administer fluid replacement by IV.

instruct the client to breathe into a paper bag.

A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should: . insert a nasogastric tube (NG) as ordered. • administer acetaminophen as ordered. • instruct the client to breathe into a paper bag. • administer antibiotics as ordered.

• All options are correct.

A client reports having increased incidence of constipation. What can cause constipation? • All options are correct. • insufficient fiber • emotional stress • inactivity

• Acute gastritis

A client reports to the clinic, stating that she rapidly developed headache, abdominal pain, nausea, hiccuping, and fatigue about 2 hours ago. For dinner, she ate buffalo chicken wings and beer. Which of the following medical conditions is most consistent with the client's presenting problems? • Acute gastritis • Duodenal ulcer • Gastric cancer • Gastric ulcer

• Severed blood vessels constrict.

A client suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What will occur during this process? • Severed blood vessels constrict. • Thromboplastin is released. • Prothrombin is converted to thrombin. • Fibrin is lysed.

• Esophageal or pyloric obstruction related to scarring

A client was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? • Esophageal or pyloric obstruction related to scarring • Uncontrolled proliferation of H. pylori • Gastric hyperacidity related to excessive gastrin secretion • Chronic referred pain in the lower abdomen

• urinary tract infection

A client who has a history of neurogenic bladder presents with fever, burning, and suprapubic pain. What would the nurse suspect is the problem? • urinary tract infection • urinary incontinence • urinary retention • urethral strictures

• In the bone marrow

A client with a hematologic disorder asks the nurse how the body forms blood cells. The nurse should describe a process that takes place where? • In the spleen • In the kidneys • In the bone marrow • In the liver

• Assess the AV fistula for a bruit and thrill.

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? • Keep the AV fistula site dry. • Keep the AV fistula wrapped in gauze. • Take the client's blood pressure in the left arm. • Assess the AV fistula for a bruit and thrill.

• Throbbing headache or dizziness

A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects? • Nervousness or paresthesia • Throbbing headache or dizziness • Drowsiness or blurred vision • Tinnitus or diplopia

Cryoprecipitate

A client with disseminated intravascular coagulation (DIC) has a critically low fibrinogen level and is beginning to hemorrhage. To increase the amount of fibrinogen in the body, the nurse anticipates administering which blood product? • Cryoprecipitate • Fresh frozen plasma • Albumin • Packed red blood cells

• The client will be monitored closely to detect malignant changes.

A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care? • The client will be monitored closely to detect malignant changes. • Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. • Small amounts of blood are likely to be present in the stools and are not cause for concern. • Antacids may be discontinued when symptoms of heartburn subside.

• Retention of potassium

A client with kidney injury secondary to diabetic nephropathy has been admitted to the medical unit. What is the most life-threatening effect of kidney injury for which the nurse should monitor the client? • Accumulation of wastes • Retention of potassium • Depletion of calcium • Lack of BP control

• Reduction in sodium intake

A client with liver disease has developed ascites; the nurse is collaborating with the client to develop a nutritional plan. The nurse should prioritize which of the following in the client's plan? • Increased potassium intake • Fluid restriction to 2 L per day • Reduction in sodium intake • High-protein, low-fat diet

• Perform a thorough pain assessment.

A client with long-term breast cancer who was recently enrolled in a hospice program demonstrates signs and symptoms of clinical depression. Which action by the hospice nurse is appropriate? • Educate the client that depression is expected. • Perform a thorough pain assessment. • Ask the client whether she is planning to hurt herself. • Explain that antidepressants are not indicated for the client.

Epoetin alfa

A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells? • Filgrastim • Sargramostim • Epoetin alfa • Eltrombopag

Hemorrhage

A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, and labored breathing; the client also appears to be confused. Which of the following complications has the client most likely developed? • Hemorrhage • Penetration • Perforation • Pyloric obstruction

Low hematocrit

A client with sickle cell anemia has a Low hematocrit High hematocrit Normal hematocrit Normal blood smear

• "Do you feel any muscle twitches or spasms?"

A client with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the client should prioritize what question when addressing potential complications? • "Do you feel any muscle twitches or spasms?" • "Do you feel flushed or sweaty?" • "Are you experiencing any dizziness or lightheadedness?" • "Are you having any pain that seems to be radiating from your bones?"

Hemophilia

A client's electronic health record states that the client receives regular transfusions of factor IX. The nurse would be justified in suspecting that this client has what diagnosis? • Leukemia • Hemophilia • Hypoproliferative anemia • Hodgkin lymphoma

• "DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs."

A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC? • "DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs." • "DIC occurs when the immune system attacks platelets and causes massive bleeding." • "DIC is a complication of an autoimmune disease that attacks the body's own cells." • "DIC is caused when hemolytic processes destroy erythrocytes."

Anemia

A client's health history reveals daily consumption of two to three bottles of wine. The nurse should plan assessments and interventions in light of the client's increased risk for what hematologic disorder? • Leukemia • Anemia • Thrombocytopenia • Lymphoma

• Assess the client's vital signs to establish baselines.

A client's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform? • Have the client identify his or her blood type in writing. • Ensure that the client has granted verbal consent for transfusion. • Assess the client's vital signs to establish baselines. • Facilitate insertion of a central venous catheter.

• The client is likely to have increased serum creatinine levels.

A client's most recent laboratory findings indicate a glomerular filtration rate (GFR) of 58 mL/min. The nurse should recognize what implication of this diagnostic finding? • The client is likely to have a decreased level of blood urea nitrogen (BUN). • The client is at risk for hypokalemia. • The client is likely to have irregular voiding patterns. • The client is likely to have increased serum creatinine levels.

Bananas

A client's most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the client's dietary intake of potassium. What should the nurse recommend? • Apples • Fish • Rice • Bananas

• Confirm placement of the tube prior to each scheduled feeding.

A client's new onset of dysphagia has required insertion of an NG tube for feeding. What intervention should the nurse include in the client's plan of care? • Confirm placement of the tube prior to each scheduled feeding. • Have the client sip cool water to stimulate saliva production. • Keep the client in a low Fowler position when at rest. • Connect the tube to continuous wall suction when not in use.

Tented T wave

A client's potassium level is elevated. The nurse is reviewing the ECG tracing. Identify the area on the tracing where the nurse would expect to see peaks.

• Fever • New onset of confusion

A gerontologic nurse is assessing a client who has numerous comorbid health problems. What assessment findings should prompt the nurse to suspect a UTI? Select all that apply. • Food cravings • Upper abdominal pain • Insatiable thirst • Fever • New onset of confusion

• anal fissure.

A longitudinal tear or ulceration in the lining of the anal canal is termed a(n): • anorectal abscess. • anal fistula. • hemorrhoid. • anal fissure.

• gouty arthritis.

A male client comes to the clinic with complaints of pain in his right great toe. The client reports that the pain is worse at night. Assessment reveals tophi. The nurse suspects the client has: • osteoarthritis. • gouty arthritis. • rheumatoid arthritis. • reactive arthritis.

Urine output of 20 mL/hour

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? Serum potassium level of 4.9 mEq/L Serum sodium level of 135 mEg/L Temperature of 99.2 F Urine output of 20 mL/hour

The increased resistance of a narrowed orifice between the left atrium and the left ventricle

A nurse caring for a patient with mitral stenosis understands that the initial cause of disruption to the normal flow of blood through the hear is due to: The increased resistance of a narrowed orifice between the left atrium and the left ventricle Inadequate left ventricle filling Atrial hypertrophy Pulmonary circulation congestion

• Immunization • Use of standard precautions

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. • Immunization • Use of standard precautions • Consumption of a vitamin-rich diet • Annual vitamin K injections • Annual vitamin B12 injections

• The early symptoms of gastric cancer are usually not alarming or highly unusual.

A nurse is admitting a client diagnosed with late-stage gastric cancer. The client's family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor most likely contributed to the client's late diagnosis? • Gastric cancer does not cause signs or symptoms until metastasis has occurred. • Adherence to screening recommendations for gastric cancer is exceptionally low. • Early symptoms of gastric cancer are usually attributed to constipation. • The early symptoms of gastric cancer are usually not alarming or highly unusual.

• unequal response

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? • unequal response • equal response • rapid response • constricted response

• fine crackles.

A nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are: • tracheal. • fine crackles. • coarse crackles. • friction rubs.

• Positive Brudzinski's sign

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely? • Negative Kernig's sign • Positive Brudzinski's sign • Increased intake • Hyper-alertness

Impaired gas exchange

A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority? • Anxiety • Impaired gas exchange • Impaired physical mobility • Deficient knowledge: Home care

• Wear disposable gloves and protective clothing.

A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents? • Wear disposable gloves and protective clothing. • Break needles after the infusion is discontinued. • Disconnect I.V. tubing with gloved hands. • Throw I.V. tubing in the trash after the infusion is stopped.

• Monitoring for infection

A nurse is caring for a client who has a diagnosis of acute leukemia. What assessment most directly addresses the most common cause of death among clients with leukemia? • Monitoring for infection • Monitoring nutritional status • Monitor electrolyte levels • Monitoring liver function

Defibrillation

A nurse is caring for a client who is exhibiting ventricular tachycardia (VT). Because the client is pulseless, the nurse should prepare for what intervention? • Defibrillation • ECG monitoring • Implantation of a cardioverter defibrillator • Angioplasty

• Respiratory failure

A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD? Lung cancer Pneumothorax Respiratory failure Hemothorax

• maintaining the client's fluid, electrolyte, and acid-base balance.

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is: • planning for the client's rehabilitation and discharge. • providing emotional support to the client and family. • maintaining the client's fluid, electrolyte, and acid-base balance. • preserving full range of motion in all affected joints.

• Pepsin

A nurse is promoting increased protein intake to enhance a client's wound healing. What is the enzyme that will initiate the digestion of the protein that the client consumes? • Pepsin • Intrinsic factor • Lipase • Amylase

• Frequent lung auscultation

A nurse is providing care for a client with a diagnosis of late-stage Alzheimer disease. The client has just returned to the medical unit to begin supplemental feedings through an NG tube. Which of the nurse's assessments addresses this client's most significant potential complication of feeding? • Frequent assessment of the client's abdominal girth • Assessment for hemorrhage from the nasal insertion site • Frequent lung auscultation • Vigilant monitoring of the frequency and character of bowel movements

• Low-fat foods high in proteins and carbohydrates

A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? • High-fiber foods • Low-purine, nutrient-dense foods • Low-fat foods high in proteins and carbohydrates • Foods that are low-residue and low in fat

• Brushing the client's teeth with a toothbrush and small amount of toothpaste

A nurse is providing oral care to a client who is comatose. What action best addresses the client's risk of tooth decay and plaque accumulation? • Irrigating the mouth using a syringe filled with a bactericidal mouthwash • Applying a water-soluble gel to the teeth and gums • Wiping the teeth and gums clean with a gauze pad • Brushing the client's teeth with a toothbrush and small amount of toothpaste

• 20 minutes

A nurse is teaching a client about peritoneal dialysis. The nurse should tell the client the dwell time is: • 10 minutes • 20 minutes • 30 minutes • 60 minutes

• Recognition of hypoglycemia and hyperglycemia

A nurse is teaching basic "survival skills" to a client newly diagnosed with type 1 diabetes. What topic should the nurse address? • Signs and symptoms of diabetic nephropathy • Management of diabetic ketoacidosis • Effects of surgery and pregnancy on blood sugar levels • Recognition of hypoglycemia and hyperglycemia

• Weight reduction • Increased physical activity • Substitution of low-fat for whole dairy products in diet

A nurse providing education to a community group about hypertension is reviewing appropriate lifestyle modifications. Which of the following are among changes that can help prevent and control hypertension? Choose all that apply. Weight reduction Increased physical activity Increased intake of dietary sodium Increased intake of dietary protein Substitution of low-fat for whole dairy products in diet

• Diabetes, hypercholesterolemia, and hypertension

A nurse records a client's history and discovers several risk factors for coronary artery disease (CAD). Which cardiac risk factors can the client control? • Diabetes, hypercholesterolemia, and heredity • Diabetes, age, and gender • Age, gender, and heredity • Diabetes, hypercholesterolemia, and hypertension

• Physical activity, dietary sodium, and the DASH diet

A nursing class is practicing the measurement of blood pressure. The finding in one otherwise healthy man, 36 years old, is 130/88. This man requires follow-up for prehypertension. Which of the following lifestyle factors would the nurse discuss with the client? Physical activity, dietary sodium, and the DASH diet • Physical activity, needed medication, and the DASH diet • Weight reduction, the DASH diet, and physical activity • The DASH diet, sexual dysfunction related to required medications, and physical activity

Sinus tachycardia

A patient comes to the emergency department with complaints of chest pain after using cocaine. The nurse assesses the patient and obtains vital signs with results as follows: blood pressure 140/92, heart rate 128, respiratory rate 26, and an oxygen saturation of 98%. What rhythm on the monitor does the nurse anticipate view? Sinus bradycardia Ventricular tachycardia Normal sinus rhythm Sinus tachycardia

• altered oral mucous membranes.

A patient has been NPO for two days anticipating surgery which has been repeatedly delayed. In addition to risks of nutritional and fluid deficits, the nurse determines that this patient is at the greatest risk for: • altered oral mucous membranes. • physical injury. • ineffective social interaction. • confusion.

• Pulmonary crackles • Dyspnea • Cough

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.) • Jugular vein distention • Ascites • Pulmonary crackles • Dyspnea • Cough

Low blood pressure

A patient is receiving anticoagulant therapy. The nurse should be alert to potential signs and symptoms of external or internal bleeding, as evidenced by which of the following? Low blood pressure High blood pressure Decreased heart rate Elevated hematocrit

• Excess fluid volume

A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely? • Excess fluid volume • Risk for imbalanced nutrition, more than body requirements • Deficient fluid volume • Impaired urinary elimination

• B-type natriuretic peptide (BNP)

A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure? • Blood urea nitrogen (BUN) • Complete blood count (CBC) • B-type natriuretic peptide (BNP) • Serum electrolytes

Heart

A physician treating a client in the cardiac care unit for atrial arrhythmia orders metoprolol (Lopressor), 25 mg P.O two times per day. Metoprolol inhibits the action of sympathomimetics at beta1 - receptor sites. Where are these sites mainly located? Uterus Blood vessels Bronchi Heart

• lack of free water intake

A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation? • lack of free water intake • lack of solid food • lack of exercise • increased fiber

• lack of free water intake

A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation? • lack of free water intake • lack of solid food • lack of exercise • increased fiber

• Impaired nutrition: less than body requirements

A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority? • Disturbed body image • Impaired nutrition: less than body requirements • Nausea • Anxiety

• "How many alcoholic drinks do you typically consume in a week?"

A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation? • "How many alcoholic drinks do you typically consume in a week?" • "To the best of your knowledge, are your immunizations up to date?" • "Have you ever worked in an occupation where you might have been exposed to toxins?" • "Has anyone in your family ever experienced symptoms similar to yours?"

• Serum potassium level

After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent dysrhythmias? • Serum potassium level • Serum calcium level • Serum sodium level • Serum chloride level

Kidneys

After teaching a class about the endocrine system, the instructor determines that the students need additional instruction when they identify which of the following as an endocrine gland? • Pancreas • Adrenal gland • Testes • Kidneys

• Fluids must be increased to facilitate the evacuation of the stool.

An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test? • Stool will be yellow for the first 24 hours postprocedure. • The barium may cause diarrhea for the next 24 hours. • Fluids must be increased to facilitate the evacuation of the stool. • Slight anal bleeding may be noted as the barium is passed.

• The different leukemias all involve unregulated proliferation of white blood cells.

An oncology nurse is providing health education for a client who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia? • The different leukemias all involve unregulated proliferation of white blood cells. • The different leukemias all have unregulated proliferation of red blood cells and decreased bone marrow function. • The different leukemias all result in a decrease in the production of white blood cells. • The different leukemias all involve the development of cancer in the lymphatic system.

• The defibrillator won't deliver a shock if the synchronizer switch is turned on.

Before using a defibrillator to terminate ventricular fibrillation, a nurse should check the synchronizer switch. Why is this check so important? • The delivered shock must be synchronized with the client's QRS complex. • The defibrillator won't deliver a shock if the synchronizer switch is turned on. • The defibrillator won't deliver a shock if the synchronizer switch is turned off. • The shock must be synchronized with the client's T wave.

• Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing

During a blood transfusion with packed red blood cells (RBCs), a client reports chills, low back pain, and nausea. What priority action should the nurse take? • Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing • Discontinue the infusion immediately and notify the physician • Slow the infusion rate and continue to monitor the client every 15 minutes • Observe for additional symptoms and notify the physician

• All options are correct.

Hypertension is defined as "sustained elevations in systolic or diastolic blood pressures that exceed prehypertension levels." What are some of the consequences of hypertension that make it such a health menace in the United States? All options are correct. cardiac failure cerebrovascular accident renal disease

Pulse oximetry

In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a client's arterial oxygen saturation (SaO2). What procedure will best accomplish this? • Incentive spirometry • Arterial blood gas (ABG) measurement • Peak flow measurement • Pulse oximetry

• To decrease workload of the heart

In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD? • To dilate coronary arteries • To decrease workload of the heart • To decrease homocysteine levels • To prevent angiotensin II conversion

• Potassium of 2.8 mEq/L

It is important for the nurse to monitor serum electrolytes in a patient with acute diarrhea. Select the electrolyte result that should be immediately reported. • Chloride of 100 mEq/L • Sodium of 136 mEq/L • Calcium of 9 mg/dL • Potassium of 2.8 mEq/L

• Stimulation of calcium reabsorption and phosphate excretion

Parathyroid hormone (PTH) has which effects on the kidney? • Stimulation of calcium reabsorption and phosphate excretion • Stimulation of phosphate reabsorption and calcium excretion • Increased absorption of vitamin D and excretion of vitamin E • Increased absorption of vitamin E and excretion of vitamin D

• Heart rate of 42 beats per minute (bpm).

Sam, a retired professional NFL player, visits his cardiologist for his annual physical. The nurse takes an ECG and notices an abnormal finding. However, the nurse realizes that this result can be normal when present without symptoms. This finding is a: • PR interval of 0.18 seconds. • Heart rate of 42 beats per minute (bpm). • QT interval of 0.37 seconds. • P-to-QRS ratio of 1:1.

• Gay, bisexual, and other men who have sex with men

Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV? • Gay, bisexual, and other men who have sex with men • Recreational drug users • Blood transfusion recipients • Health care providers

• Full-thickness

Skin grafts are necessary for which of the following burns? • Superficial • Superficial partial thickness • Full-thickness • First degree

• Glucocorticoids and androgens

The adrenal cortex is responsible for producing which substances? • Glucocorticoids and androgens • Catecholamines and epinephrine • Mineralocorticoids and catecholamines • Norepinephrine and epinephrine

Semi - Fowlers

The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in which of the following positions.

• Verify that the client has signed a written consent form.

The client is to receive a unit of packed red blood cells. The first intervention of the nurse is to • Check the label on the unit of blood with another registered nurse. • Ensure that the intravenous site has a 20-gauge or larger needle. • Observe for gas bubbles in the unit of packed red blood cells. • Verify that the client has signed a written consent form.

• Monitoring neurologic status closely

The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? • Maintaining the client's functional independence • Providing health education • Monitoring neurologic status closely • Promoting mobility

• Visual inspection

The diagnosis of a skin disorder is made chiefly by which of the following? • Palpation • Visual inspection • Biopsy • Culture

Signs and symptoms of respiratory complications

The home care nurse is visiting a client newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? • Resumption of the client's ADLs • The family's willingness to care for the client • Nutritional status and fluid balance • Signs and symptoms of respiratory complications

• Respiratory depression

The nurse administers an opioid analgesic to a patient. What serious side effect should the nurse carefully monitor for? • Renal toxicity • Respiratory depression • Seizure activity • Hypertension

1500

The nurse begins a routine blood transfusion of packed red blood cells (PRBCs) at 1100. To ensure client safety, the unit of blood should be completely transfused by what time? • 1115 • 1500 • 1530 • 1600

• difficulty swallowing

The nurse cares for a client after a gastroscopy for which the client received sedation. The nurse should report which finding to the physician? • loss of gag reflex • minor throat pain • drowsiness • difficulty swallowing

• Evaluation of gag reflex and ability to swallow

The nurse determines which nursing intervention would best assist the client with a brain tumor who may be at increased risk for aspiration? • Evaluation of gag reflex and ability to swallow • Monitoring vital signs • Assistance with self-care • Frequent reorientation

• Decreased oxygen level.

The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level? • Bright red venous blood. • Elevated temperature. • Decreased oxygen level. • Increased bruising.

Dehydration

The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure? Dehydration Hyperkalemia Crackles Hypertension

• Refrain from eating or drinking for now.

The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to • refrain from eating or drinking for now. • have their spouse bring in the client's glasses. • wear any hearing aids while in the hospital. • use the walker when walking.

• Disorientation and restlessness

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? • Disorientation and restlessness • Decreased pulse and respirations • Projectile vomiting • Loss of corneal reflex

• Nasogastric tube insertion

The nurse in the ED admits a client with suspected gastric outlet obstruction. The client's symptoms include nausea and vomiting. The nurse anticipates that the physician will issue which order? • Pelvic x-ray • Stool specimen • Nasogastric tube insertion • Oral contrast

pa02

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicated to the nurse that the patient is experiencing hypoxemia? pa02 pH PCo2 HCo3

pH: 7.20, PaCO2: 65 mm Hg, HCO3: 26 mEq/L

The nurse is analyzing the arterial blood gas (ABG) results of a client diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? pH: 7.20, PaCO2: 65 mm Hg, HCO3: 26 mEq/L pH: 7.32, paCO2: 40 mm Hg, HCO3: 18 mEq/L pH: 7.50, paCO2: 30 mm Hg, HCO3: 24 mEq/L pH: 7.42, PaCO2: 45 mm Hg, HCO3: 22 mEq/L

Hematemesis

The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage? • Hematemesis • Bradycardia • Hypertension • Polyuria

They can be heard during inspiration and expiration

The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes? They result from air passing through widened air passages. They can be heard during inspiration and expiration They are heard in clients with decreased secretions They occur when the pleural surfaces are inflamed

Fatigue

The nurse is caring for a client diagnosed with hypothyroidism secondary to Hashimoto thyroiditis. When assessing this client, what sign or symptom would the nurse expect? • Fatigue • Bulging eyes • Palpitations • Flushed skin

• Lying on the left side with legs drawn toward the chest

The nurse is caring for a client scheduled for a colonoscopy. The nurse should assist the client into what position during this diagnostic test? • In a knee-chest position (lithotomy position) • Lying prone with legs drawn toward the chest • Lying on the left side with legs drawn toward the chest • In a prone position with two pillows elevating the buttocks

• Decreased hematocrit

The nurse is caring for a client who had undergone hemodilution during surgery. Immediately after surgery, the nurse expects to see which lab result? • Elevated erythrocyte concentration • Elevated creatinine • Critically low arterial oxygen saturation • Decreased hematocrit

• An increased urine specific gravity

The nurse is caring for a client who has a fluid volume deficit. When evaluating this client's urinalysis results, what should the nurse anticipate? • A fluctuating urine specific gravity • A fixed urine specific gravity • A decreased urine specific gravity • An increased urine specific gravity

• Lipids and fibrous tissue

The nurse is caring for a client who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what? • Lipids and fibrous tissue • White blood cells • Lipoproteins • High-density cholesterol

• Mottling of the lower limbs

The nurse is caring for a client who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the client's death is imminent? • Mottling of the lower limbs • Slow, steady pulse • Bowel incontinence • Increased swallowing

• Heart failure

The nurse is caring for a client whose acute kidney injury has prerenal cause. What most likely caused this client's health problem? • Heart failure • Glomerulonephritis • Ureterolithiasis • Aminoglycoside toxicity

The need for lifelong steroid replacement

The nurse is caring for a client with Addison disease who is scheduled for discharge. When teaching the client about hormone replacement therapy, the nurse should address what topic? • The possibility of precipitous weight gain • The need for lifelong steroid replacement • The need to match the daily steroid dose to immediate symptoms • The importance of monitoring liver function

• Ambulation and activity as tolerated

The nurse is caring for a client with hyperparathyroidism. What level of activity would the nurse expect to promote? • Complete bed rest • Bed rest with bathroom privileges • Out of bed (OOB) to the chair twice a day • Ambulation and activity as tolerated

• The urethra

The nurse is caring for a client with recurrent urinary tract infections. Which of the following body structures would the nurse instruct as the most frequent cause of women's urinary tract infections? • The urethra • The bladder • The rectum • The ureters

• Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)

The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? • Ineffective breathing pattern related to decreased cardiac output • Anxiety related to fear of death • Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) • Impaired skin integrity related to CAD

• Maintain firm contact between paddles and the client's skin.

The nurse is caring for an adult client who has gone into ventricular fibrillation. When assisting with defibrillating the client, what must the nurse do? • Maintain firm contact between paddles and the client's skin. • Apply a layer of water as a conducting agent. • Call "all clear" once before discharging the defibrillator. • Ensure the defibrillator is in the sync mode.

Constipation

The nurse is caring for an older client whose chart reveals that the client has a reversible cause of urinary incontinence. The nurse creates a plan of care for which condition? • Asthma • Bladder cancer • Constipation • Decreased progesterone levels

Prehypertension

The nurse is completing a cardiac assessment on a patient. The patient has a blood pressure (BP) reading of 126/80. The nurse would identify this blood pressure reading as which of the following? • Prehypertension Normal • Stage 1 hypertension • Stage 2 hypertension

"Do you currently smoke, or have you ever smoked?"

The nurse is completing a client's health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases? • "Have you ever been employed in a factory, smelter, or mill?" • "Does anyone in your family have any form of lung disease?" • "Do you currently smoke, or have you ever smoked?" • "Have you ever lived in an area that has high levels of air pollution?"

• The tube is radiopaque.

The nurse is inserting a sump tube in a patient with Crohn's disease who is suspected of having a bowel obstruction. What does the nurse understand is the benefit of the gastric (Salem) sump tube in comparison to some of the other tubes? • The tube is radiopaque. • The tube is shorter. • The tube is less expensive. • The tube can be connected to suction and others cannot.

• Maintains effective respirations and airway clearance

The nurse is planning care for a client with Guillain-Barre syndrome. The priority client outcome would be which of the following? • Maintains effective respirations and airway clearance • Shows increasing mobility • Receives adequate nutrition and hydration • Demonstrates recovery of speech

• Inspection, auscultation, percussion, and palpation

The nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow? • Inspection, auscultation, percussion, and palpation • Inspection, palpation, auscultation, and percussion • Inspection, percussion, palpation, and auscultation • Inspection, palpation, percussion, and auscultation

• Maintaining a patent airway

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? • Maintaining accurate records of intake and output • Maintaining a patent airway • Inserting a nasogastric (NG) tube as prescribed • Providing appropriate pain control

• A benzodiazepine

The nurse is providing care for an older adult client whose current medication regimen includes levothyroxine. As a result, the nurse should be aware of the heightened risk of adverse effects when administering an IV dose of what medication? • A fluoroquinolone antibiotic • A loop diuretic • A proton pump inhibitor (PPI) • A benzodiazepine

• Maintain adequate cardiac output.

The nurse is writing a plan of care for a client with a cardiac dysrhythmia. What would be the priority goal for the client? • Maintain a resting heart rate below 70 bpm. • Maintain adequate control of chest pain. • Maintain adequate cardiac output. • Maintain normal cardiac structure.

• 3.5-5.0 mEq/L (3.5-5.0 mmol/L).

The nurse knows which is the normal serum value for potassium? • 135-145 mEq/L (135-145 mmol/L). • 96-106 mEq/L (96-106 mmol/L). • 3.5-5.0 mEq/L (3.5-5.0 mmol/L). • 8.5-10.5 mg/dL (2.13-2.63 mmol/L).

• Jugular venous distention

The nurse should notify the healthcare provider before administering fresh frozen plasma (FFP) based on which assessment finding? • White sclera • Jugular venous distention • Strong pedal pulses • Absence of tenting skin turgor

• Avoid eating or drinking 2 hours before bedtime

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? • Minimize intake of caffeine, beer, milk, and foods containing peppermint or spearmint • Avoid eating or drinking 2 hours before bedtime • Elevate the foot of the bed on 6- to 8-inch blocks • Eat a low-carbohydrate diet

• Void immediately after sexual intercourse.

The nurse who teaches a client about preventing recurrent urinary tract infections would include which statement? • Take tub baths instead of showers. • Void immediately after sexual intercourse. • Increase intake of coffee, tea, and colas. • Void every 5 hours during the day.

• Presence of a painless sore with raised edges

The nurse's comprehensive assessment of a client includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages? • Dull pain radiating to the ears and teeth • Presence of a painless sore with raised edges • Areas of tenderness that make chewing difficult • Diffuse inflammation of the buccal mucosa

• QRS complex

The nursing educator is presenting a case study of an adult client who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? • P wave • T wave • QRS complex • U wave

• Verify the client's identity according to hospital policy

The physician orders a transfusion with packed red blood cells (RBCs) for a client hospitalized with severe iron deficiency anemia. When blood is administered, what is the most important action the nurse can take to prevent a transfusion reaction? • Verify the client's identity according to hospital policy • Administer the blood as soon as it arrives • Premedicate the client with acetaminophen • Assess the client 30 minutes after the start of the initial transfusion

• pH • PaCO2 • HCO3

To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. • pH • PaCO2 • HCO3 • Glucose • Na+ • K+

• cannot tolerate a high glucose concentration.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because they • are at risk for gallbladder contraction. • are at risk for hepatic encephalopathy. • can digest high-fat foods. • cannot tolerate a high glucose concentration.

• removal of the transplanted kidney.

Twenty-four hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for: • removal of the transplanted kidney. • high-dose IV cyclosporine (Sandimmune) therapy. • bone marrow transplant. • intra-abdominal instillation of methylprednisolone sodium succinate (Solu-Medrol).

• Adhere to dosing recommendations of over-the-counter analgesics.

What health promotion teaching should the nurse prioritize to prevent drug-induced hepatitis? • Finish all prescribed courses of antibiotics, regardless of symptom resolution. • Adhere to dosing recommendations of over-the-counter analgesics. • Ensure that expired medications are disposed of safely. • Ensure that pharmacists regularly review drug regimens for potential interactions.

Hypercapnia, hypoventilation and hypoxemia

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problem? Hypotension, hyeroxemia, and hypercapnia Hyperventilation, hypertension, and hypocapnia Hyperoxemia, hypocapnia, and hyperventilation Hypercapnia, hypoventilation and hypoxemia

• Intervertebral disk herniation

When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose an example of chronic pain. • A migraine headache • Intervertebral disk herniation • Angina • Appendicitis

• History of pancreatitis

When reviewing the history of a client with pancreatic cancer, the nurse would identify which of the following as a possible risk factor? • History of pancreatitis • Ingestion of a low-fat diet • One-time exposure to petrochemicals • Ingestion of caffeinated coffee

• A deep sunburn

Which assessment finding indicates an increased risk of skin cancer? • A deep sunburn • A dark mole on the client's back • An irregular scar on the client's abdomen • White irregular patches on the client's arm

• presents with a rigid, boardlike abdomen.

Which client requires immediate nursing intervention? The client who: • complains of epigastric pain after eating. • complains of anorexia and periumbilical pain. • presents with a rigid, boardlike abdomen. • presents with ribbonlike stools.

Bisacodyl

Which drug is considered a stimulant laxative? • Magnesium hydroxide • Bisacodyl • Mineral oil • Psyllium hydrophilic mucilloid

African population

Which ethnic background would the nurse screen for hypertension at an early age? • Asian population • Japanese population • Mexican population • African population

• Retinal blood vessel damage

Which finding indicates that hypertension is progressing to target organ damage? Retinal blood vessel damage Urine output of 60 mL over 2 hours Blood urea nitrogen concentration of 12 mg/dL Chest x-ray showing pneumonia

Petechiae

Which is a symptom of severe thrombocytopenia? • Petechiae • Inflammation of the mouth • Inflammation of the tongue • Dyspnea

0.9% normal saline

Which is considered an isotonic solution? • 0.9% normal saline • Dextran in normal saline • 0.45% normal saline • 3% NaCl

• Change in bowel habits

Which is the most common presenting symptom of colon cancer? • Fatigue • Change in bowel habits • Anorexia • Weight loss

• Severe, radiating abdominal pain

Which is the most common report by clients with pancreatitis? • Tarry, black stools and dark urine • Increased and painful urination • Increased appetite and weight gain • Severe, radiating abdominal pain

• Withholding all oral intake, as ordered, to decrease pancreatic secretions

Which nursing action is most appropriate for a client hospitalized with acute pancreatitis? • Withholding all oral intake, as ordered, to decrease pancreatic secretions • Administering meperedine, as ordered, to relieve severe pain • Limiting I.V. fluids, as ordered, to decrease cardiac workload • Keeping the client supine to increase comfort

• Risk for injury related to vertigo

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease? • Acute pain related to vertigo • Imbalanced nutrition: Less than body requirements related to nausea and vomiting • Risk for deficient fluid volume related to vomiting • Risk for injury related to vertigo

Pituitary

Which of the following glands is considered the master gland? • Pituitary • Thyroid • Parathyroid • Adrenal

• Elevated blood urea nitrogen (BUN) and creatinine • Rapid onset • More common in type 1 diabetes

Which of the following is a characteristic of diabetic ketoacidosis (DKA)? Select all that apply. • Elevated blood urea nitrogen (BUN) and creatinine • Rapid onset • More common in type 1 diabetes • Absent ketones • Normal arterial pH level

• Peripheral tingling

Which of the following is a mild systemic reaction to anaphylaxis? • Peripheral tingling • Flushing • Anxiety • Itching

Vaccine

Which of the following is the most effective strategy to prevent hepatitis B infection? • Vaccine • Barrier protection during intercourse • Covering open sores • Avoid sharing toothbrushes

• Lactated Ringer's (LR)

Which of the following is the preferred IV fluid for burn resuscitation? • Lactated Ringer's (LR) • Normal saline (NS) • D5W • Total parenteral nutrition (TPN)

• Ineffective Tissue Perfusion

Which of the following nursing diagnosis is the nurse most correct to choose when caring for a client with long-standing hypertension? • Impaired Gas Exchange • Activity Intolerance • Ineffective Tissue Perfusion • Risk for Decreased Cardiac Output

Hourly urine output • Daily weights

Which of the following provides clues about fluid volume status? Select all that apply. • Hourly urine output • Daily weights • Percentage of meals eaten • Skin turgor • Oxygen saturation

• Hourly urine output • Daily weights

Which of the following provides clues about fluid volume status? Select all that apply. • Hourly urine output • Daily weights • Percentage of meals eaten • Skin turgor • Oxygen saturation

Heart transplant

Which of the following therapies are for patient who have advanced heart failure (HF) after all other therapies have failed? Heart transplant Ventricular access device Implantable cardiac defibrillator Cardiac resynchronization therapy

• Feet, ankles

Which particular area(s) should be examined to assess peripheral edema? • Uppper arms • Under the sacrum • Lips, earlobes • Feet, ankles

Paracentesis

Which term describes the passage of a hollow instrument into a cavity to withdraw fluid? • Asterixis • Paracentesis • Ascites • Dialysis

Hernia

Which term refers to a protrusion of the intestine through a weakened area in the abdominal wall? • Tumor • Hernia • Volvulus • Adhesion

Pancytopenia

Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? • Pancytopenia • Anemia • Leukopenia • Thrombocytopenia

Pancytopenia

Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? • Pancytopenia • Anemia • Leukopenia • Thrombocytopenia

• Superficial partial-thickness

Which type of burn is similar to a sunburn? • Superficial partial-thickness • Electrical • Deep partial-thickness • Full-thickness

• Use an electric razor when assisting client with shaving.

While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client? • Use an electric razor when assisting client with shaving. • Elevate the client's head of the bed. • Where a mask when entering the client's room. • Apply supplemental oxygen to maintain the client's oxygenation.

100 mL

• The client is to receive cephalexin (Ancef) 500 mg in 50 mL of normal saline intravenous piggyback. The medication is to infuse over 30 minutes. How many mL/hr would the nurse set the intravenous pump? Enter the correct number ONLY.