Quiz 1

A nurse is caring for a client with a retroperitoneal abscess who is receiving gentamicin 300 mg intravenously every 8 hours. Which client data would the nurse monitor? Select all that apply. 1. hearing 2. urine output 3.HCT 4. BUN and serum creatinine levels 5. serum calcium level 6. muscle tone

1,2,4

The nurse is preparing to administer a 75% strength tube-feeding formula. The full-strength formula is available. To prepare 500 ml of feeding, the nurse would plan to dilute how many milliliters of the full-strength formula with water? Record your answer as a whole number.

375

The nurse is caring for a client who is experiencing an exacercation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply. 1. Eat a low-purine dies. 2. Limit fluid intake to no more than 1 L/day. 3. Eat a high-protein diet, with at least two servings of lean meat per day. 4. Limit sodium intake to 1,500 mg/day. 5. Limit alcohol intake.

1,5

The nurse is caring for a client during the postsurgical period after having a right femo-ral-popliteal bypass graft. The nurse enters the room to conduct a nursing assessment and care. Order the nurse's actions according to priority. All options must be used. 1. Offer clear fluids. 2. Assess pain/ obtain medication. 3. Assess incision site. 4. Assess lung fields. 5. Assess peripheral pulses. 6. Instruct on client positioning.

5,3,4,2,6,1

A client returns from the operating room after undergoing extensive abdominal surgery. The client is receiving 1,000 ml of lactated Ringer's solution via a central line infusion. The health care provider orders the intravenous fluid to be infused at 125 ml/hour and additional intravenous fluids based on total output of the last hour. The drip factor of the tubing is 15 gtt/ml, and the output for the previous hour was 75 ml via Foley catheter, 50 ml via nasogastric tube, and 10 ml via Jackson-Pratt tube. For how many drops (gtt) per minute would the nurse set the intravenous flow rate to deliver the correct amount of fluid? Record your answer as a whole number.

65

A client with sepsis and hypotension is being treated with dopamine hydrochloride. A nurse asks a colleague to double-check the dosage that the client is receiving. The 250-ml bag contains 400 mg of dopamine, the infusion pump is running at 23 ml/hour, and the client weighs 80 kg. How many micrograms per kilogram per minute is the client receiving? Record your answer using one decimal point.

7.7

The nurse is preparing to administer phenytoin to a 99-Ib (45 kg) client with a seizure disorder. The medication administration record documents phenytoin 5 mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin would be administered in the first dose? Record your answer as a whole number.

75

A client diagnosed with gastroenteritis and mild dehydration has a history of being unable to tolerate oral intake for 3 days. Intravenous therapy is prescribed. The nurse anticipates administering what solution to treat the mild dehydration?

D5.45 NS solution injection usp

A nurse is interpreting a client's ECG strip. If the PR interval measures four small blocks, how many seconds is the PR interval? Record your answer using two decimal places.

0.16

A client who underwent cardiac surgery has been prescribed morphine sulfate 2 mg intravenously for pain. The morphine sulfate is packaged as 2 mg/ml. The nurse dilutes the medication in 4 ml of sterile water and prepares to administer the medication over 5 minutes. If the nurse administers 1 ml of fluid every minute, how many milligrams of morphine will be administered per minute? Record your answer using one decimal point.

0.4

A nurse is assessing the abdomen of a client who was admitted to the emergency department with suspected appendicitis. Identify the area of the abdomen that the nurse would palpate last.

RLL

The nurse is reviewing a client's urine culture and sensitivity test results. Which findings would the nurse expect to see in small amounts in normal urine? Select all that apply. 1. ketones 2. protein 3. white blood cells 4. crystals 5. nitrates 6. bilirubin

2,3

A nurse is caring for a client diagnosed with a cerebral aneurysm. The health care provider orders hydralazine 15 mg intravenously every 4 hours as needed to keep the systolic blood pressure less than 140 mm Hg. To administer the correct dose, how many milliliters of medication would the nurse draw up in the syringe? Record your answer using two decimal places.

0.75

A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic head injury. The health care provider calls and asks for a report on the client's condition. Based on the documentation below, how would the nurse respond? 1. "The client's ICP remains elevated." 2. "The client's ICP has decreased to lower than normal limits." 3. "The client's ICP is within normal limits." 4. "The client's ICP was elevated but now has returned to normal."

1

The nurse is caring for a client who sustained a head injury during a football game. The nurse is completing the following examination. Which documentation by the nurse provides normal results of this examination? 1. The client's pupils are equal and reactive to light and accommodation. 2. The client's retina is attached, with no signs of tearing. 3. The client's vision is 20/20 in both eyes. 4. The client's visual field is 360°.

1

A nurse is presenting health information at a community organization when one of the attendees passes out. The nurse assesses the attendee as being unresponsive. Indicate how the nurse would respond by placing the following actions in chronological order. All options must be used. 1. Appoint a person to call 911. 2. Check for a pulse. 3. Deliver two rescue breaths. 4. Check for normal breathing. 5. Perform chest compressions. 6. Perform a head tilt-chin lift maneuver.

1,5,6,4,3,2

A nurse is explaining self-catheterization to a female client who has been diagnosed with urogenic bladder. Which instructions would the nurse include in the home teaching? Select all that apply. 1. Tampons may remain in place during menstruation. 2. The meatus would be cleaned with a towelette or soapy washcloth and then rinsed. 3. Sterile technique is not required. 4. A new intermittent catheterization set would be used each time. 5. Finding the urinary meatus always requires visualization with a mirror.

2,3

The nurse is assessing laboratory values to identify if medical treatment and nursing interventions have improved Kidney function in a client with renal disease. Which laboratory tests will the nurse monitor to determine the functioning status of the kidneys? Select all that apply. 1. urine culture 2. urine albumin 3. glomerular filtration rate (GFR) 4. creatinine clearance 5. basic metabolic panel (BMP) 6. hemoglobin A1C

2,3,4,5

A nurse is preparing a staff education program on innovative devices in pulmonary circulation. Beginning with basic concepts, place the following structures in chronological order to trace the pathway of normal pulmonary circulation. All options must be used. 1. pulmonary vein 2. right ventricle 3. pulmonary artery 4. arterioles 5. alveoli 6. left atrium

2,3,4,5,1,6

The nurse is assisting a client to ambulate to the bathroom following a bowel resection for diverticulitis. Suddenly, the client reports a sharp abdominal pain. The nurse assesses the client and determines the wound has eviscerated. Prioritize the following nursing actions in chronological order to show how the nurse would respond. All options must be used. 1. Assess the client's response. 2. Call for assistance from other nursing personnel. 3. Document the incident, including the client's condition. 4. Cover the wound with sterile, nonadherent dressing moistened with sterile normal saline solution. 5. Place the client in low Fowler's position. 6. Notify the surgeon.

2,5,4,1,6,3

The nurse is caring for a senior citizen who lives alone. When evaluating the effectiveness of adding fluticasone propionate salmeterol to the chronic obstructive airway disease (COPD) client's medication regimen , when chent sidements would support symptom improvement? Select all that apply: 1. "I have noted an increase in sputum 2. "I have begun walking upstairs to use the bathroom." 3. "I can rely on the medication when I have an exacerbation of symptoms." 4. "I seem to feel nervous and shaky making me more productive." 5. "I can now push my granddaughter on the swings when she visits." 6. "The nurse aide no longer comes to the house to help me bathe."

2,5,6

A nurse is caring for a client with pneumonia who was prescribed ceftriaxone oral suspension 600 mg once daily. The medication label indicates that the strength is 125 mg/5 ml. How many milliliters of medication would the nurse pour to administer the correct dose? Record your answer as a whole number.

24

A client with deep vein thrombosis is receiving an intravenous infusion of heparin sodium at 1,500 units/hour. The concentration in the bag is 25,000 units/500 ml. How many milliliters would the nurse document as intake from this infusion for an 8-hour shift? Record your answer using a whole number.

240

The client has been admitted to the emergency department with severe midepigastric, upper quadrant abdominal pain. Based on the signs and symptoms and laboratory data documented in the chart below, the nurse would anticipate preparing for which diagnosis? 1. peptic ulcer 2. Crohn's disease 3. pancreatitis 4. irritable bowel syndrome

3

A nurse is caring for a client with pulmonary edema whose respiratory status is declining. Chronologically arrange the nursing interventions to prioritize care. All options must be used. 1. Initiate oxygen via nasal cannula at 2 L/ minute: 2. Call the health care provider. 3. Position the client upright at a 45° angle. 4. Prepare suctioning equipment at the bedside. 5. Administer furosemide 40 mg intravenously STAT. 6. Insert an indwelling urinary catheter.

3,1,4,2,5,6

A nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse would be alert for which occurrence? Select all that apply. 1. Trousseau's sign 2. cardiac arrhythmias 3. constipation 4. decreased clotting time 5. drowsiness and lethargy 6. fractures

1,2,6

The nurse is caring for a client who possibly may need kidney dialysis. When evaluating the client's renal function to report to the health care provider, which data will the nurse use? Select all that apply. 1. a client's 24-hour urinary output 2. glomerular filtration rate 3. trending vital signs 4. a client's flank pain level 5. the blood count report 6. serum creatinine level

1,2,6

A nurse is evaluating a client with primary pulmonary hypertension for a heart-lung trans-plant. Which medication treatment would the nurse anticipate to be included in the plan of care? Select all that apply. 1. oxygen therapy 2. aminoglycosides 3. diuretics 4. vasodilators 5. antihistamines 6. sulfonamides

1,3,4

17lb client with minimal urine output has been prescribed dopamine at 5 pg/kg/minute. The premixed medication bag contains 800 mg of dopamine in 500 ml dextrose 5% in water. How many milliliters of solution would the nurse administer each hour? Record your answer as a whole number.

15

A client comes to the emergency department with status asthmaticus. Based on the documentation noted below, the nurse suspects that the client has what abnormality? 1. respiratory acidosis 2. respiratory alkalosis 3. metabolic acidosis 4. metabolic alkalosis

2

A nurse assesses a client with suspected bacterial meningitis. Which documented findings of meningeal irritation suggest this diagnosis? Select all that apply. 1. tinnitus 2. nuchal rigidity 3. positive Brudzinski's sign 4. positive Kernig's sign 5. babinski's reflex 6. photophobia

2,3,4,6

A client is prescribed lisinopril for the treatment of hypertension. The client asks a nurse about possible adverse effects. Which common adverse effects of angiotensin-converting enzyme (ACE) inhibitors would the nurse include in the teaching? Select all that apply. 1. constipation → diarrnca 2. dry cough 3. headache 4. hyperglycemia 5. hypotension 6. impotence

2,3,5

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung trans-plant. Which initial assessment data would the nurse anticipate? Select all that apply. 1. decreased respiratory rate 2. dyspnea on exertion 3. barrel chest 4. shortened expiratory phase 5. unintended weight loss 6. fever

2,3,5

A nurse is assessing a clients extraocular eye movements as part of evaluating neurological func-tioning. This documents the status of which cranial nerves? Select all that apply. 1. optic (Il) 2. oculomotor(III) 3. trochlear (IV) 4. trigeminal (V) 5. abducens (VI) 6. acoustic (VIII)

2,3,5

A nurse is calling report to the medical surgical floor staff regarding a client with acute diverticulitis. Which symptoms does the nurse anticipate? Select all that apply. 1. esophagitis 2. cramping pain in the left lower abdominal quadrant 3. bowel irregularity 4. heartburn 5. intervals of diarrhea 6. hiccuping

2,3,5

The nurse is caring for several clients on the respiratory unit who are receiving the ß-adrenergic agonist bronchodilator albuterol in the prescribed nebulizer treatments. Which side effects would the nurse expect to assess following administration? Select all that apply. 1. increased tachypnea 2. irritability and nervousness 3. tachycardia 4. increased somnolence 5. insomnia 6. anxiety

2,3,5,6

A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member; the monitor exhibits the following. Which intervention would the nurse do first? 1. Place the client on oxygen. 2. Confirm the rhythm with a 12-ead ECG. 3. Administer amiodarone I.V. as prescribed. 4. Assess the client's airway, breathing, and circulation.

4

The nurse is caring for a client following a segmental resection of the lung because of the presence of a malignant mass. The nurse explains to the family the difference between various types of lung excisions. Which picture best documents a segmental resection?

4

The nurse is preparing to interpret an ECG rhythm strip. Place the following steps for ECG rhythm analysis from first to last, in chronological order. All options must be used. 1. Measure the QRS duration. 2. Interpret the rhythm. 3. Analyze the P waves. 4. Determine the rate and rhythm. 5. Measure the PR interval.

4,3,5,1,2

A client is admitted with inflammatory bowel syndrome (Crohn's disease). When planning care for the health care team, which would be included? Select all that apply. 1. lactulose therapy 2. high-fiber diet 3. high-protein milkshakes 4. corticosteroid therapy 5. antidiarrheal medications

4,5

The nurse is evaluating how a client with hepatitis A understands the discharge teaching given. Which client statements indicate that further teaching is needed? Select all that apply. 1. "I can have an occasional glass of wine with my meal as I recover." 2. "My family and I do not need to take any special precautions as long as I take my medication." 3. "My bath towels shouldn't be used by any other family members." 4. "My family members should receive the hepatitis A vaccine to prevent them from getting the disease." 5. "My spouse and I can have intercourse and kiss." 6. "I should wear a mask when visitors come."

1,2,5,6

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply. 1. a client who is on complete bed rest following extensive spinal surgery 2. a client who has a large venous stasis ulcer on the right ankle area 3. a client who has recently been admitted with a broken femur and is awaiting. 4. a client who has a pleural effusion secondary to infection. 5. a client who is receiving supplemental oxygen following shoulder surgery. 6. a client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy.

1,2,3,6

The nurse is caring for a client who is scheduled to undergo a computed tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in the extremities. Which information would the nurse include in a preprocedural teaching plan? Select all that apply. 1. The test may require removal of watches, bracelets, or earrings. 2. A contrast dye may be given before the test. 3. Throat irritation and facial flushing may occur if contrast dye is used. 4. All medications must be withheld for 12 hours prior to the procedure. 5. The CT scan is considered an invasive procedure, but not dangerous. 6. It is necessary to report any known allergies to iodine or seafood prior to the procedure.

1,2,3,6

The nurse is caring for a client with stress incontinence who is ordered a cystometrography. The client inquires about the nature of the proce dure. Place in chronological order the sequence of events for this procedure. All options must be used. 1. Client is asked to void normally. 2. Urinary catheter is inserted. 3. Fluid is instilled into the urinary catheter. 4. Any residual urine is noted. 5.Client is asked to void following instillation. 6. Urge to void is recorded.

1,2,3,6,5,4

A client requires behavioral therapies to decrease or eliminate urinary incontinence. Which procedures would the nurse expect to include in the teaching plan for this client? Select all that apply. 1. Kegel exercises 2. scheduled voiding 3. external catheters 4. biofeedback 5. self-catheterization devices 6. postvoid residual monitoring

1,2,4

A nurse is caring for a client newly diagnosed with osteoporosis. Which statements would the nurse include when teaching the client about the disease? Select all that apply. 1. Osteoporosis is common in females after menopause. 2. Osteoporosis is a degenerative disease characterized by a decrease in bone density. 3. Daily medication is needed to cure the disease. 4. Osteoporosis can cause pain and injury. 5. Passive ROM exercises can promote bone growth. 6. Limit weight bearing and repetitive exercises.

1,2,4

A nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and blood pressure of 174/100 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be appropriate for this client? Select all that apply. 1. Elevate the head of the bed to 90°. 2. Loosen constrictive clothing. 3. Use a fan to reduce diaphoresis. 4. Assess for bladder distention and bowel impaction. 5. Administer antihypertensive medication as ordered. 6. Administer morphine as ordered.

1,2,4,5

A nurse is caring for a client with history of heart failure and presenting with symptoms indicating a pulmonary embolism. The nurse documents admission findings of sudden shortness of breath, chest pain, and immobility. Which nursing diagno. ses are admission priorities? Select all that apply. 1. activity intolerance related to inadequate oxygenation 2. anxiety related to breathlessness 3. disturbed sleep pattern related to restlessness in the night 4. ineffective breathing pattern related to hypoxia 5. risk for decreased cardiac output related to failure of the left ventricle 6. impaired nutrition: less than body requirements related to anorexia

1,2,4,5

A client with a suspected pulmonary embolus is brought to the emergency department stating shortness of breath and chest pain. Which additional signs and symptoms are anticipated? Select all that apply. 1. anxiety 2. irregular heartbeat 3. bradycardia 4. frothy sputum 5. tachycardia 6. blood-tinged sputum

1,2,5,6

The nurse is evaluating the cardiac function of a client with history of left ventricular hypertro-phy and new diltiazem administration. Which client statements indicate therapeutic use of diltiazem leading to adequate cardiac functioning? Select all that apply. 1. "I am sleeping well in the second floor bedroom." 2. "I am tolerating my new low-fat diet." 3. "My blood pressure has been consistently in the 130/70 range." 4. "I am completing all of my activities of daily living independently." 5. "In the morning, I notice 2 plus edema in my ankles." 6. "My lab results reveal a serum potassium of 3.5 mEq/L (3.5 mmol/L)."

1,3,4

A nurse is providing discharge instructions on phenytoin to a female client with tonic-clonic seizure disorder. Which instructions would the nurse include? Select all that apply. 1. Monitor the body for any skin rash. 2. Maintain adequate amounts of fluid and fiber in the diet. 3. Perform good oral hygiene, including daily brushing and flossing. 4. Receive necessary periodic blood work. 5. Report any problems with walking or coordination, slurred speech, or nausea.

1,3,4,5

While managing a client's immediate post-cardiac catheterization period, which interventions are priorities? Select all that apply. 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess all peripheral pulses frequently. 3. Restrict the client to bed rest for 2 to 6 hours. 4. Assess the catheter insertion site every 30 minutes for 4 hours. 5. Note any limb discoloration and reported numbness. 6. Assess for any signs of hematoma formation.

1,3,4,5,6

A nurse is caring for a client following gastric bypass surgery. At the 6-week appointment, the client reports symptoms of nausea, abdominal pain and cramping following meals, and shakiness and sweating up to 3 hours later. Which nursing interventions would help reduce the symptoms and be included in the plan of care? Select all that apply. 1. Eat small, frequent meals. 2. Limit sodium intake. 3. Reduce high concentrated sugars. 4. Ingest fluids at the end of meals. 5. Refer the client to a dietician

1,3,5

A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the client's score has changed from 11 to 15. Which responses did the nurse assess in this client? Select all that apply. 1. spontaneous eye opening 2. tachypnea, bradycardia, and hypotension 3. unequal pupil size 4. orientation to person, place, and time 5. pain localization 6. incomprehensible sounds

1,4

A nurse is caring for a client with a traumatic injury and developing tension pneumothorax. Which assessment data would be of concern? Select all that apply. 1. decreased cardiac output 2. flattened neck veins 3. tracheal deviation to the affected side 4. hypotension 5. tracheal deviation to the unaffected side 6. bradypnea

1,4,5

The nurse is caring for a client admitted with cirrhosis of the liver. Which laboratory results are consistent with the disease process? Select all that apply. 1. prothrombin time 22 seconds 2. potassium 4.0 mEq/L (4.0 mmol/L) 3. albumin 7.2 g/di (72 g/L) 4. ammonia 96 mg/dl (68.54 mmol/L) 5. platelets 75,000 cells/mm' (75 10/L) 6. amylase 250 units/L (4.18 ukat/L)

1,4,5

A nurse is caring for a client with Raynaud's phenomenon secondary to systemic lupus erythe-matosus (SLE). Which of the client statements demonstrates an understanding of the nurse's teaching about this disorder? Select all that apply. 1. "My hands get pale and bluish and feel numb and painful when I'm really stressed." 2. "I can't continue to wash dishes and do my cleaning because of this problem." 3. "I don't need to report any other skin problems with my fingers or hands to my health care provider." 4. "I probably got this disorder because I am also diagnosed with lupus." 5. "This problem is caused by a temporary lack of circulation in my hands." 6. "I will have to discuss medication that might treat this problem with my health care provider."

1,4,5,6

A nurse is caring for a client, diagnosed with Alzheimer's disease, who scored a 7 (high risk) on the Hendrich Il Fall Risk Model. Which nursing interventions would the nurse implement? Select all that apply. 1. Implement a bed alarm. 2. Place the overbed table next to bed. 3. Instruct the client to ask for help before ambulating. 4. Maintain the bed in the lowest position. 5. Offer toileting every 2 to 3 hours. 6. Advise family to notify staff when leaving.

1,4,5,6

A nurse is counseling a client about risk factors for hypertension. While reviewing the client's history, which information is consistent with the diagnosis of primary hypertension? Select all that apply. 1. obesity 2. glomerulonephritis 3. head injury 4. stress 5. hormonal contraceptive use 6. high intake of sodium or saturated fat

1,4,6

The nurse is caring for a client with nephropathy. The health care provider orders a 24-hour urine collection. Which actions are necessary to ensure proper collection of the specimen? Select all that apply. 1. Collect the urine in a preservative-free container and keep on ice. 2. Inform the client to discard the last voided specimen at the conclusion of urine collection. 3. Ask the client what his/her weight is for documentation on the container. 4. Request an order for insertion of an indwelling urinary catheter. 5. Encourage daily amounts of fluids. 6. Discard the initial voiding but save all others for 24 hours.

1,5,6

After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an intravenous line with dextrose in 5% water infusing at 40 ml/hour and a triple-lumen urinary catheter with normal saline solution infusing at 200 ml/hour. The nurse empties the urinary catheter drainage bag three times during an 8-hour period for a total of 2,780 ml. How many milliliters would the nurse calculate as urine? Record your answer as a whole number.

1180

A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution intravenously over 5 minutes. The client weighs 132 lb. How many grams would the nurse administer? Record your answer as a whole number.

12

A nurse is caring for a client who recently had a bowel resection. The client has a hemoglobin level of 8 g/d and HCT of 30%. Dextrose 5% in half-normal saline solution (D$½NS) is infusing through a triple-lumen central catheter at 125 ml/ hour. The health care provider's orders include: • gentamicin 80 mg intravenous piggyback in 50 ml DsW over 30 minutes • ranitidine 50 mg intravenous in 50 ml • D5W piggyback over 30 minutes • one unit of 250 ml of packed red blood cells (RBCs) over 3 hours • nasogastric tube flushes with 30 ml of normal saline solution every 2 hours How many milliliters would the nurse document as the total intake for the 8-hour shift? Record your answer as a whole number.

1470

A client presents to the emergency department with right facial droop and drooling. A diagnosis of Bell's palsy is confirmed by a neurological exam and magnetic resonance imaging (MRI). When instructing the spouse on the interventions needed to care for the client, which spouse statements need clarification by the nurse? Select all that apply. 1. "I will buy a clothing protector for feedings." 2. "I will obtain a walker in case symptoms progress." 3. "I will instill eye drops to prevent symptoms of dry eyes." 4. "I will watch for further symptoms of a stroke. 5. "I will reinforce that symptoms are usually temporary." 6. "I will provide sunglasses during the daytime."

2,4

While preparing a client for an upper Gl endoscopy (esophagogastroduodenoscopy), the nurse would be correct to implement which intervention? Select all that apply. 1. Administer a preparation to cleanse the GI tract, such as GOLYTELY or Fleets Phospho-Soda. 2. Instruct not to eat or drink for 6 to 12 hours before the procedure. 3. Teach only to ingest a clear liquid diet for 24 hours before the procedure. 4. Inform the client of receiving a sedative before the procedure. 5. Encourage the client to eat and drink immediately after the procedure.

2,4

A nurse is assigned a client with an acute exacerbation of rheumatoid arthritis (RA). Which medical facts about RA are essential in developing a plan of care? Select all that apply. 1. Onset is acute and usually occurs between ages 20 and 40. 2. The client experiences stiff, swollen joints bilaterally. 3. The client may not exercise once the disease is diagnosed. 4. Erythrocyte sedimentation rate (ESR) is elevated, and x-rays show erosions and decalcification of involved joints. 5. Inflamed cartilage triggers complement activation, which stimulates the release of additional inflammatory mediators. 6. The first-line treatment is gold salts and methotrexate.

2,4,5

A nurse is putting groceries in the car when an older adult client falls off of a curb. The nurse assesses the client and has a bystander call for an ambulance. Which assessment findings provide data of a suspected right hip fracture? Select all that apply. 1. The right leg is longer than the left leg. 2. The right leg is shorter than the left leg. 3. The right leg is abducted. 4. The right leg is adducted. 5. The right leg is externally rotated. 6. The right leg is internally rotated.

2,4,5

A nurse is caring for a client with a new prescription of digoxin. Which client statement would require further teaching about digoxin? Select all that apply. 1. "I will take the digoxin at 9 AM daily." 2. "I will take the digoxin with my antacids at night." 3. "I will take my pulse before each dose of digoxin." 4. "If I forget a dose, I will catch up by doubling the next dose." 5. "I will notify my health care provider if experiencing increased fatigue or muscle weakness." 6. "Understand that I will need annual blood work to check therapeutic levels."

2,4,6

The registered nurse (RN) is assigned a client with stomach cancer, who has just returned from a subtotal gastrectomy. Which nursing interventions would be delegated to either a licensed practical/vocational nurse (LPN/VN) or a nursing assistant/unregistered health care worker (UHW)? Select all that apply. 1. Administer carboplatin 750 mg intravenously. 2. Document intake and output in the electronic medical record. 3. Assess bowel sounds in all four quadrants. 4. Reinforce tape over an abdominal incision 5. Ambulate in the hall for the first time after surgery. 6. Provide report for the next shift.

2,4,6

A fireman is admitted with superficial skin wounds and a sprained back following an intense fire. No respiratory concerns are verbalized. Nearly 24 hours after admission, the fireman reports dyspnea, a harsh cough, and hoarseness. Which nursing interventions would the nurse add to the plan of care? Select all that apply. 1. Monitor for fever. 2. Prepare the chest for chest tube insertion. 3. Auscultate the lungs for adventitious breath sounds. 4. Assess for increased pulse rate. 5. Monitor for increased anxiety levels.

3,4,5

A nurse is awaiting the arrival of a client from the emergency department with a diagnosis of anterior wall myocardial infarction. In caring for this client, the nurse would be alert for which signs and symptoms of left-sided heart failure? Select all that apply. 1. jugular vein distention 2. hepatomegaly 3. dyspnea 4. crackles 5. tachycardia 6. skin tenting

3,4,5

client is admitted to the emergency department after reporting acute chest pain radiating down the left arm. The client appears anxious, dys-pneic, and diaphoretic. Which laboratory studies would the nurse anticipate? Select all that apply. 1. hemoglobin and hematocrit (HCT) 2. serum glucose 3.creatine kinase (CK) 4. troponin T and troponin l 5. myoglobin 6. blood urea nitrogen (BUN)

3,4,5

A nurse is evalues on the 12-lead ECG of a client experiencing ar inferior wall myocardial infarction (MI). While conferring with the heath care team, which ECS changes associated with an evolving MI does this nurve correctly identify? Select all that apply. 1. notched T wave 2. presence of a U 3. T-wave inversion 4. prolonged PR 5. ST-segment elevation

3,5

The registered nurse (RN) is assisting the licensed practical nurse (LPN) in performing a purified protein derivative (PPD) test on a nursing home resident. Which statements about this test are correct? Select all that apply. 1. A PPD test is done to test for allergies. 2. Always aspirate before injecting the PPD solution. 3. The PPD test is an intradermal test. 4. Hold the syringe at a 45° angle to the 5. The preferred injection site is the ventral surface of the forearm. 6. No wheal should appear at the site following injection.

3,5

A client is hospitalized following a report of dizziness, shortness of breath, and chest pain. Based on the ECG rhythm, the client is scheduled for a transesophageal echocardiogram (TEE) today. Which nursing interventions would be appropriate at this time? 1. Initiate a heparin drip. 2. Encourage deep breathing exercises. 3. Prepare the client for immediate electrical cardioversion. 4. Administer oxygen via nasal cannula as Prescribed.

4

A nurse is caring for a client with a wound infection who develops septic shock. The nurse notes the following arterial blood gas results: pH of 7.25, PaCO2 of 43 mm Hg (43 mmol/L), partial pressure of arterial oxygen (PaOz) of 70 mm Hg (9.31 kPa), and bicarbonate (HCO3) of 18 mEa/L (18 mmol/L). According to the oxyhemoglobin dissociation curve, the nurse would be most correct to highlight which finding on shift report? 1. The client's profile reflects alkalosis. 2. The client's hemoglobin saturation is close to 100%. 3. The client's oxyhemoglobin curve is shifted to the left. 4. The client's hemoglobin saturation is close to 85%.

4

A nurse is preparing discharge instructions for an above-the-knee amputation client. Which instructions would be a priority for home care? Select all that apply. 1. Massage the residual limb in a motion away from the suture line. 2. Avoid using heat application to ease pain. 3. Immediately report twitching, spasms, or phantom limb pain. 4. Avoid exposing the skin around the residual limb to excessive perspiration. 5. Be sure to perform the prescribed exercises. 6. Rub the residual limb with a dry washcloth for 4 minutes three times daily if the limb is sensitive to touch.

4,5,6

A nurse is caring for a client diagnosed with pneumonia, a urinary tract infection, dehydration, and temperature of 101.4°F (38.6°C). The health care provider orders 1,000 ml of D,W to infuse over 8 hours. The available drop factor is 20 gtt/ ml. The nurse would regulate the intravenous flow rate to deliver how many drops per minute? Round your answer to the nearest whole number.

42

The rehabilitation nurse is caring for a client with a health history of multiple sclerosis (MS) for 10 years. Recently, the nurse has seen a significant decline in the client's function. When reevaluating the client's plan of care, the nurse considers the client's physiologic changes associated with the decline. Arrange the following degenerative changes in the order in which they occur. All options must be used. 1. degeneration of axons 2. demyelination throughout the central nervous system 3. periodic and unpredictable exacerbations and remissions 4. plaque formation that interrupts nerve impulses 5. the immune system attacks myelin

5,2,1,4,3

A nurse is preparing to teach students in a health class about hearing pathways. Place the following steps in chronological order to match how the nurse would describe the normal pathway of sound wave transmission and hearing to the class. All options must be used. 1. interpretation of sound by the cerebral cortex 2. transmission of vibrations through the hammer, anvil, and stirrup 3. stimulation of nerve impulses in the inner ear 4. transmission of vibrations to the auditory area of the cerebral cortex 5. collection of the sound waves in the pinna

5,2,3,4,1

A client is scheduled to undergo cerebral angiography to allow for examination of the cerebral arteries. Place the following interventions in the order in which the nurse would perform them. All options must be used. 1. Administer antianxiety medication if ordered. 2. Confirm no allergies to iodine, seafood, or radiopaque dyes. 3. Make sure the client has signed an informed consent form. 4. Maintain the affected extremity in straight alignment for 6 hours as ordered. 5. Encourage the client to verbalize questions about the procedure with nurse and health care provider.

5,3,2,1,4