RN Concept-Based Assessment Level 2 Online Practice B, ATI Practice Exam

The nurse is providing discharge teaching to a client about managing diverticulitis. Which of the following statements should the nurse include in the teaching? -"Use bisacodyl suppositories to stimulate a bowel movement" -"Avoid lifting objects greater than 50 pounds" -"Consume a clear liquid diet until symptoms resolve" -"Take a probiotic 15 minutes after taking a prescribed antibiotic to prevent antibiotic-related diarrhea"

"Consume a clear liquid diet until symptoms resolve" The nurse should recommend the client consume a clear liquid diet until manifestations such as abdominal pain, nausea, and vomiting have resolved. A clear liquid diet is low in fiber and does not stimulate intestinal motility.

A nurse is leading a small group discussion in an acute care mental health facility when one client suddenly begins to experience a panic attack. Which of the following actions should the nurse take? A: Teach the client how to use breathing techniques while continuing the discussion. B: Remain with the client until manifestations subside. C: Speak in a high-pitched louder voice to gain the client's attention. D: Instruct the client to join another group who is practicing yoga

.B: Remain with the client until manifestations subside. -The nurse should remain with the client in a quiet place throughout the panic attack to ensure the client's safety and assist with anxiety reduction techniques.

A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition for a malabsorption disorder. Which of the following findings should the nurse identify as an indication that the client's nutritional status is improving? -Intake of fluid is less than output of urine over the past 2 days -1kg (2.2 lb) weight gain over the past 2 days -Blood glucose 206 mg/dL -Prealbumin 13 mg/dL

1 kg (2.2 lb) weight gain over the past 2 days Total parenteral nutrition is administered to clients who have inflammatory bowel disorders and are unable to tolerate enteral nutrition. A weight gain of 0.5 kg (1.1 lb) daily is an indication that the client is responding to the parenteral nutrition.

A nurse is preparing to mix NPH insulin aspart in a single syringe for a client who has type 2 diabetes mellitus. Identify the sequence the nurse should follow.

1. Inject air into the vial equal to the amount of NPH insulin prescribed 2. Inject air into the vial equal to the amount of insulin aspart prescribed 3. Withdraw the prescribed volume of insulin aspart into the syringe 4. Withdraw the prescribed volume of NPH insulin into the syringe

A nurse is evaluating a client's understanding of dietary teaching to treat hyperlipidemia. Which of the following menu choices by the client indicates an understanding of the teaching?

A black bean burger on a whole grain bun

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for developing respiratory acidosis? -fever -abdominal ascites -anxious -nasogastric suctioning

A client who has abdominal ascites The nurse should identify that a client who has abdominal ascites can experience a restriction of chest expansion, which impairs gas exchange and places the client at an increased risk for developing respiratory acidosis.

A nurse is teaching a client who recently lost his partner to a terminal illness. The client asks how his 4-year-old son is expected to react to the death of his partner. Which of the following information should the nurse include in the teaching? -A preschooler has no concept of death -A preschooler is often interested in what happens to the body after death -A preschooler often believes that death is reversible -A preschooler understands that death happens to everyone

A preschooler often believes that death is reversible The nurse should identify that preschoolers tend to have difficulty understanding the reality of death and often believe that it is reversible. Because of magical thinking, the preschooler might think that his thoughts or behavior might have caused the person to die.

A nurse in an ED is caring for a client who has heat stroke. Which of the following actions should the nurse take to treat this form of hyperthermia? A. Apply ice packs to the clients axillae, neck, groin and chest B. Administer aspirin to the client C. Initially offer the client cool, oral fluids D. Continue cooling measures until the clients rectal temp is 99

A. Apply ice packs to the clients axillae, neck, groin and chest -The nurse should recognize that treatment for heat stroke involves cooling the client's core body temperature quickly. The nurse should apply ice to the client's axillae, neck, groin, and chest while also spraying the client's body with tepid water.

A nurse is assessing a client who has a calcium level of 6.3. Which of the following findings should the nurse expect? A. Circumoral tingling B. Hypoactive reflexes C. Fatigue D.. Anorexia

A. Circumoral tingling -The nurse should identify that hypocalcemia causes paresthesias, which is circumoral numbness and tingling of the fingers, toes, and around the mouth.

A nurse is providing discharge planning for a client who has gestational diabetes. Which of the following interventions should the nurse identify as the priority? A. Determine the clients knowledge regarding gestational diabetes B. Explain the effects of gestational diabetes on the pregnancy and fetus with the client C. Discuss dietary meal plans for gestational diabetes with he client D> Tell the client about manifestation of hypoglycemia

A. Determine the clients knowledge regarding gestational diabetes - assess the client. It is important for the nurse to determine the client's knowledge level regarding the disease process. This provides the nurse with information regarding where to start with the client teaching process.

A nurse is assessing a client who reports a new onset of joint pain and stiffness. Which of the following findings should the nurse identify as an indication of osteoarthritis? A. Improves with rest B. both arms and should bilaterally C. emotional upset exacerbates joint pain D. Client is 35 yrs old

A. Improves with rest

A nurse is assessing a client who is receiving morphine via a PCA pump to manage postoperative pain. The client has an HR of 66 and an RR of 9. Which of the following medications should the nurse anticipate the provider will prescribe for the client? A. Naloxone B. Flumazenil C. Acetylcysteine D. Glucagon

A. Naloxone

A nurse is teaching an older adult client who has peripheral neuropathy about a new prescription for duloxetine. Which of the following client statements indicates an understanding of the teaching? A: "It might take several weeks to notice an improvement in my symptoms. "B: "I will need to take this medication on an empty stomach." C: "I should take a daily ibuprofen for generalized aches." D: "I will need to decrease my dietary sodium intake while taking this medication."

A: "It might take several weeks to notice an improvement in my symptoms.

A hospice nurse is caring for a preschooler who has a terminal illness. One of the child's parents tells the nurse that it is too difficult to cope any longer and has decided to move out of the house. Which of the following responses should the nurse make? A: "Let's talk about a few ways you have dealt with stress in the past." B: "I believe that you will regret that decision. Your family needs your support." C: "I agree that you have to do what is best for your well-being at this time." D: "I think you should try to put your feelings aside and focus solely on your child."

A: "Let's talk about a few ways you have dealt with stress in the past."

A nurse is teaching a client ways to prevent osteoporotic fractures due to osteoporosis. Which of the following information should the nurse include in the teaching? A: "Maintain bone health by eating fruits, vegetables, and protein." B: "Tamsulosin can slow the progression of bone deterioration." C: "Walk 20 minutes two times a week to manage osteoporosis." D: "Start to increase vitamin C and magnesium in your diet."

A: "Maintain bone health by eating fruits, vegetables, and protein."

A nurse is providing postoperative education for a client following a laparoscopic cholecystectomy for cholelithiasis. Which of the following client statements indicates an understanding of the teaching? A: "The adhesive bandages on my incision will fall off as the incision heals." B: "I will be able to take a shower in 1 week." C: "I will need to follow a liquid diet for the first 3 days after surgery." D: "I can begin to resume my normal activity level in 2 weeks."

A: "The adhesive bandages on my incision will fall off as the incision heals."

A nurse is teaching a client who has a new prescription for finasteride to treat benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching? A: "You might need to take the medication for several months before seeing any relief." B: "This medication will cause an increase in your libido." C: "You might experience prolonged erections while taking this medication. "D: "This medication will elevate your blood pressure."

A: "You might need to take the medication for several months before seeing any relief." - client it might take 6 to 12 months before improved urinary flow occurs.

A nurse is assessing a school-age child who has appendicitis with possible perforation. Which of the following findings should the nurse identify as a manifestation of peritonitis? A: Abdominal distention B: Bradycardia C: Hyperactive bowel sounds D: Slow, deep breathing

A: Abdominal distention -peritonitis is an inflammation of the lining of the abdominal wall. This inflammation, along with the ileus that develops, causes abdominal distention; therefore, the nurse should identify this as a manifestation of peritonitis.

A nurse in an emergency department is caring for a client whose ABG results are pH 7.31, PaCO2 50 mm Hg, and HCO3 25 mEq/L after experiencing an airway obstruction. Which of the following interventions is the nurse's priority for the client? A: Apply oxygen therapy to the client. B: Administer an anti-inflammatory medication. C: Check the client's nail beds. D: Initiate IV fluid therapy.

A: Apply oxygen therapy to the client. -The first action the nurse should take when using the airway, breathing, circulation approach to caring for a client who has respiratory acidosis is to improve the client's oxygenation. When the client's airway is patent, oxygenation and ventilation are the priorities.

A nurse has arrived at the site of an accident where a client has sustained a traumatic amputation of the big toe. Identify the sequence of steps the nurse should take to treat the musculoskeletal trauma.

A: Call 911 and examine the amputation site. B: Apply direct pressure with layers of dry cloth. C: Elevate the extremity above the client's heart. D: Find the toe and wrap it in sterile gauze in a clean cloth. E: Place the toe in a bag and place the bag in 1 part ice and 3 parts water

A nurse is providing discharge teaching for a client who has a hearing impairment. Which of the following actions should the nurse take? A: Encourage the client to repeat what the nurse has said. B: Stand to the side of the client and speak directly into the client's ear. C: Talk to the client by speaking in a loud tone of voice. D: Avoid the use of hand gestures and motions when speaking with

A: Encourage the client to repeat what the nurse has said. - repeat back what is discussed. The nurse should not rely on the client's nonverbal communications, such as a nod of the head, to ensure the client understands the information.

A nurse is assessing a 1-hour-old newborn who has hypothermia, with a temperature of 36.1° C (97° F). Which of the following manifestations should the nurse expect? A: Hypoglycemia B: Flushed skin C: Tachycardia D: Hypertonicity

A: Hypoglycemia

A nurse is providing dietary teaching for a client who has hyperlipidemia due to nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? A: Less than 30% of daily calories should come from fat. B: Decrease caloric intake to less than 25 cal/kg/day. C: Increase sodium intake. D: Limit daily intake of foods high in carbohydrates.

A: Less than 30% of daily calories should come from fat. - instruct the client to choose foods low in fat and ensure that less than 30% of her daily total caloric intake is from fat. Limiting daily fat intake will improve lipid levels.

A nurse in an emergency department is caring for a client who reports abdominal pain, vomiting, and appears dehydrated. The client's ABG results are pH 7.28, PaCO2 36 mm Hg, and HCO3 14 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis

A: Metabolic acidosis

A nurse is caring for a client who has had prolonged vomiting, has an NG tube for gastric decompression, and is receiving total parenteral nutrition. The client's ABG results are pH7.48, PaCO2 50 mm Hg, and HCO3 30 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? A: Metabolic alkalosis B: Metabolic acidosis C: Respiratory acidosis D: Respiratory alkalosis

A: Metabolic alkalosis

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? (Select all the apply.) A: Nocturia B: Dependent edema C: Dyspnea D: Hacking cough E: Anorexia

A: Nocturia C: Dyspnea D: Hacking cough

A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? A: Numbness of hands B: Gingival hyperplasia C: Clay-colored stools D: Carotid bruits

A: Numbness of hands -pernicious anemia is caused by a lack of vitamin B12 and can have neurologic manifestations, such as numbness and tingling of the client's extremities. Other manifestations include pale or yellow-tinged skin, glossitis, weight loss, fatigue, and problems with balance.

A nurse is assessing a client whose ABG results are pH 7.51, PaCO2 29 mm Hg, and HCO3 24 mEq/L. Which of the following findings should the nurse expect? A: Paresthesias B: Bradycardia C: Muscle flaccidity D: Respiratory depression

A: Paresthesias - respiratory alkalosis is numbness and tingling, or paresthesia, due to a decrease in calcium ionization. Other manifestations include lightheadedness, tachycardia, and cardiac dysrhythmias.

A nurse is assessing a client who reports vision impairment and is diagnosed with primary open-angle glaucoma (POAG). Which of the following findings should the nurse expect? A: Progressive loss of peripheral vision B: Opacity of the lens of the client's eye C: Impaired central vision D: Report of seeing floating dark spots

A: Progressive loss of peripheral vision

A nurse is teaching a male client who has hypertension about dietary guidelines to help manage his disorder. Which of the following instructions should the nurse include? A: Reduce sodium intake to 1,500 mg/day or less. B: Maintain a BMI of 30. C: Add high-protein sources, such as beef and pork, to the diet. D: Limit alcohol consumption to no more than three drinks per day.

A: Reduce sodium intake to 1,500 mg/day or less. -The nurse should instruct the client to keep his daily sodium intake below 1,500 mg/day. Reducing sodium intake can lower both systolic and diastolic blood pressure.

A nurse is teaching the parent of a school-age child who has pediculosis capitis about treating this parasitic infestation. Which of the following instructions should the nurse include? A: Wash bedding, clothes, and towels in hot water in a washing machine. B: Rinse the child's hair with vinegar three times a day. C: Seal items that are not machine washable in plastic bags for 1 week. D: Boil the child's combs, brushes, and hair clips for 5 min.

A: Wash bedding, clothes, and towels in hot water in a washing machine. -wash all cloth items the child has been in contact with in hot water and dry them on a hot setting in a clothes dryer for 20 min. This helps kill any lice or nits in these items.

A nurse in an emergency department is assessing a client who displays manifestations of a small bowel obstruction. Which of the following findings should the nurse expect? Select all that apply

Abdominal distention, vomiting, hyperactive bowel sounds

A nurse is assessing a newly admitted client who has an intense fear of heights. Which of the following clinical names for this fear should the nurse document in the client's medical record?

Acrophobia

A nurse is reviewing the laboratory records of a client who has AIDS. Which of the following laboratory results should the nurse review to determine if the client is at risk for malnutrition?

Albumin level

A nurse is caring for a school-age child who was admitted to the emergency department for acute asthma exacerbation. Which of the following actions should the nurse take first?

Apply humidified oxygen with simple mask

A nurse a reviewing the laboratory report of a client who is taking atorvastatin. Which of the following findings should the nurse identify as an indication that the medication is having an adverse effect?

Aspartate aminotransferase (AST) 45 units/L

A nurse is assessing a preschool-age child who has chickenpox. The parent asks the nurse how to treat the child's fever. Which of the following responses should the nurse make?

Avoid giving aspirin to your child

A nurse is caring for a client who has a fear of open spaces. Which of the following clinical names for this fear should the nurse document in the clients medical records? A. Pyrophobia B. Agoraphobia C. Monophobia D. Astraphobia

B. Agoraphobia - fear of being outside and can be debilitating and limit a client's ability to function.

A nurse is providing teaching to a client who is experiencing malabsorption related to lactose intolerance. Which of the following foods should the nurse recommend to the client as the best nondairy source of calcium A. Ground beef B. Collard greens C. Cauliflower D. Walnuts

B. Collard greens

A nurse is caring for a client who has left hemiparesis following a stroke. Which of the following actions should the nurse take? A. Use a gait belt and stand on the clients right side to assist with ambulation B. Encourage the client to use wide grip utensils when eating with his right hand C. Place personal items on the bedside table close to the bed on the clients left side D. Remove rolled toilet paper from the holder for easier access for the client

B. Encourage the client to use wide grip utensils when eating with his right hand - to use wide-grip utensils when eating with the right hand, which can accommodate a weak grasp and encourage independence in eating.

A nurse is teaching a client who is at moderate risk for osteoporosis about ways to help prevent this disease. Select all of the above A. Avoid sun exposure B. Increase dairy product intake C. Engage in weight-bearing exercises regularly D. Increase phosphate intake E. Reduce excessive caffeine intake

B. Increase dairy product intake C. Engage in weight bearing exercises regularly E. Reduce excessive caffeine intake

A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider? A. Presence of a transparent cornea B. Presence of strabismus C. Pinna moderately extends outward from the skull D. Walls of peripheral aspect of the auditory canal are pink

B. Presence of strabismus -The nurse should recognize that the presence of strabismus, or crossing of the eyes, should disappear by 4 months of age. If this is not corrected by 4 to 6 years of age, it can lead to amblyopia; therefore, the nurse should report this finding to the provider.

A nurse on a mental health unit is developing a plan of care for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse identify as the priority? A. Reduce environmental stimulation B. Protect the client from harm C. Administer an anxiolytic D. Encourage physical exercise

B. Protect the client from harm - greatest risk to this client is injury from uncontrollable thoughts and activity

A nurse is planning care for a client who has generalized anxiety disorder? Which of the following interventions should the nurse include in the clients plan of care? A. give the client detailed instructions B. Reframe situations in a positive manner for the client C. Speak in a brisk manner to the client D. Avoid involving the client in problem solving

B. Reframe situations in a positive manner for the client - tend to worry excessively about the impact of various situations and events. Reframing them positively offers the client a fresh perspective and helps adjust his thought distortions.

A nurse is reviewing the medical record of a client who has a family history of gallstones. Which of the following findings should the nurse identify as a risk factor for developing cholecystitis? A. Adult male B. Takin atorvastatin C. Asians descent D. History of asthma

B. Takin atorvastatin - increased serum cholesterol and taking cholesterol-lowering medications, such as atorvastatin, increases the client's risk of developing cholecystitis.

A nurse is assessing a client for manifestations of grief after having a colostomy for removal of colon cancer. Which of the following findings indicates to the nurse that the client has accepted the loss? A. Becomes angry when it is time to perform colostomy care B. Touches the colostomy stoma when the bag is changed C. Looks away as the nurse empties the colostomy bag D. Tells others that it will be nice to have a normal bowel movement again

B. Touches the colostomy stoma when the bag is changed -The client touching the colostomy stoma when the bag is changed should indicate to the nurse that the client is accepting and coping with the alteration of body image and has gone through the stages of grief.

A nurse in an ED is assessing a client who has hyperthermia. Which of the following findings should the nurse identify as an indication that the client has heat exhaustion? A. Hallucinations B. Vomiting C. Bradycardia D. Seizures

B. Vomiting - heat exhaustion is usually the result of excess sweating, leading to dehydration. Manifestations include nausea, vomiting, headache, dizziness, fainting, and a temperature typically between 38.3º C and 38.9º C

A school nurse is teaching an adolescent who has diabetes mellitus about preventing hypoglycemia during and after baseball practice. Which of the following instructions should the school nurse include? A: "Inject your insulin into the upper thigh on practice days." B: "Consume an extra snack before practice." C: "Increase your regular insulin dosage before lunch on practice days." D: "Take a glucose tablet with a high-carbohydrate beverage after practice."

B: "Consume an extra snack before practice."

A nurse is teaching a client who has tuberculosis about taking rifampin. Which of the following instructions should the nurse include? A: "Expect this medication to give your urine a greenish tinge." B: "Do not drink alcohol while taking this medication." C: "Take this medication with food." D: "Take a stool softener for the duration of therapy with this medication."

B: "Do not drink alcohol while taking this medication." -rifampin could cause liver damage. Alcohol intensifies this risk. Rifampin is contraindicated for clients who have liver disease or consume alcohol in excess.

A nurse is teaching a client who has a deep-vein thrombosis about a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching? A: "I will stop taking the medication immediately if I experience nausea." B: "I should contact my provider if I notice a pink-tinged color to my urine." C: "I will increase my dietary intake of spinach." D: "I will not be able to use an electric razor while I am taking this medication."

B: "I should contact my provider if I notice a pink-tinged color to my urine."

A nurse is providing teaching to a client who has chronic obstructive pulmonary disease (COPD). Which of the following statements should indicate to the nurse that the client understands the teaching?A: "I should drink 1.5 liters of water daily to keep hydrated." B: "I should make my abdomen rise with each inhalation." C: "I should inhale through my mouth and exhale through my nose." D: "I should limit walks to 10 minutes daily in order to conserve my energy."

B: "I should make my abdomen rise with each inhalation."

A nurse is teaching a client who has asthma about using a metered-dose inhaler. Which of the following client statements indicates an understanding of the teaching? A: "I'll roll the canister between my palms a few times before using it." B: "I'll take a deep breath and blow it out before I inhale the medication." C: "I'll hold the mouthpiece 3 inches in front of my mouth before depressing the canister." D: "I'll hold my breath for up to 5 seconds after inhaling the medication."

B: "I'll take a deep breath and blow it out before I inhale the medication."

A nurse is teaching a client who has hypothyroidism about taking levothyroxine. Which of the following statements should the nurse make? A: "You'll need to take this medication once a day at bedtime." B: "This medication causes adverse effects if the dosage is too high or too low." C: "Continuing this medication therapy long-term will eventually cure your hypothyroidism." D: "Potassium supplements can reduce the effectiveness of this medication."

B: "This medication causes adverse effects if the dosage is too high or too low."

A nurse is providing teaching for a client who has a new diagnosis of benign prostatic hyperplasia (BPH). Which of the following instructions should the nurse include to promote elimination? A: "Drink at least 24 ounces of water each hour." B: "Void as soon as you feel the urge." C: "Expect a prescription for a diuretic." D: "Take an antihistamine each night at bedtime."

B: "Void as soon as you feel the urge." -The nurse should instruct a client who has BPH on measures to prevent distension of the bladder and urinary retention. Encouraging the client to void as soon as the urge develops decreases the risk of bladder distension.

A nurse is assessing a client who reports gastrointestinal distress. Which of the following findings should indicate to the nurse that the client has cholecystitis? A: Abdominal pain triggered by spicy food B: Abdominal pain that radiates to the right shoulder C: Abdominal pain in the right lower quadrant D: Abdominal pain that is continuous over several days

B: Abdominal pain that radiates to the right shoulder - client who has cholecystitis to have abdominal pain that is episodic, typically occurring after fatty or large meals, and can radiate from the client's right upper quadrant to the right shoulder or scapula.

A nurse is planning care to prevent hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infection for a client who is immunocompromised. Which of the following interventions should the nurse include to prevent this antibiotic-resistant infection? A: Initiate contact precautions for this client. B: Bathe the client with chlorhexidine wipes. C: Administer ceftaroline to the client as a prophylactic measure. D: Avoid using alcohol-based hand sanitizers after caring for the client

B: Bathe the client with chlorhexidine wipes. -The nurse should bathe a client who is immunocompromised with chlorhexidine wipes to decrease the risk of contracting hospital-acquired MRSA.

A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse report to the provider immediately? A: WBC 16,000/mm³ B: Board-like abdomen C: Nausea and vomiting D: Temperature of 38° C (100.4° F)

B: Board-like abdomen -the nurse should identify that a board-like abdomen is the priority finding indicating peritonitis. The nurse should notify the provider immediately.

A nurse is assessing a client who has as an ulcer due to peripheral vascular disease. Which of the following findings should the nurse identify as an indication that the client has a venous ulcer rather than an arterial ulcer? A: Diminished peripheral pulsations in the right lower leg B: Discoloration and edema of the right ankle C: Atrophy of the skin and hair loss on the right leg D: Dependent rubor in the right leg

B: Discoloration and edema of the right ankle -The nurse should identify that manifestations of peripheral venous disease include discoloration and edema of the ankle, resulting from venous hypertension.

A nurse is assessing a school-age child who has diabetes mellitus and a blood glucose level of 250 mg/dL. Which of the following findings should the nurse expect? A: Hyperreflexia B: Fruity breath odor C: Sweating D: Shallow respirations

B: Fruity breath odor -The nurse should expect a child who has a blood glucose level of 250 mg/dL to have a fruity or acetone breath odor. Other manifestations include lethargy, thirst, and confusion.

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings is a priority to report to the provider? A: Melena stools B: Hemoglobin 7.6 mg/dL C: Weight gain of 1.4 kg (3 lb) in 2 weeks D: Dyspepsia during the day

B: Hemoglobin 7.6 mg/dL -below the expected reference range, which in an indication of a peptic ulcer that is chronically bleeding.

A nurse is caring for a middle adult female client who has atrial fibrillation and is taking warfarin. The nurse should recognize which of the following as an adverse effect of the medication and notify the provider? A: Clay-colored stools B: Increased menstrual flow C: Overgrowth of gingival tissue D: Dry, non-productive cough

B: Increased menstrual flow -warfarin is an anticoagulant used to prevent the development of thrombosis. It suppresses coagulation, which increases the risk for bleeding.

A nurse is caring for a client who has Cushing's disease. The nurse should identify that the client is at risk for which of the following acid-base imbalances?A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis

B: Metabolic alkalosis -This leads to an increase is renal excretion of potassium and, therefore, hypokalemia. This electrolyte imbalance puts the client at risk for metabolic alkalosis as the kidneys try to retain potassium by increasing hydrogen ion excretion, and as potassium moves out of the cells and into the extracellular fluid and hydrogen ions move into the cells.

A nurse is discussing lactose-free foods with a client who is experiencing malabsorption due to lactose intolerance. Which of the following foods should the nurse recommend? A: Sour cream B: Soy milk C: Ice cream D: Plain yogurt

B: Soy milk -The nurse should instruct the client to consume foods that are lactose-free and are nondairy products. Acceptable foods include soy milk, almond milk, and soy cheeses.

The nurse in an emergency department was caring for an adolescent who died following a motor vehicle crash. Which of the following reactions should the nurse expect the client's 10-year-old sibling to exhibit? A: The sibling believes the client will wake up in a few hours. B: The sibling is curious about what will happen to the client's body. C: The sibling will continue to treat the client as though he were still alive. D: The sibling will alienate themselves from her family and friends.

B: The sibling is curious about what will happen to the client's body. -The nurse should expect a 10-year-old child to be inquisitive about what happens to the body and what will occur during funeral or memorial services.

A nurse is teaching disease management techniques to a client who has COPD. Which of the following instructions should the nurse include in the teaching? A: Avoid activities that increase the respiratory rate. B: Use pursed-lip breathing when feeling short of breath. C: Consume a diet high in carbohydrates for increased energy. D: Limit fluid intake to 1.5 L daily

B: Use pursed-lip breathing when feeling short of breath

A nurse is developing a plan of care for a client who is scheduled to have an induction of labor due to a fetal demise. Which is the following actions should the nurse include?

Bathe, diaper, and dress the child before bringing the newborn to the client

A nurse in a provider's office is assessing a client who is taking warfarin to treat atrial fibrillation. Which of the following findings should the nurse identify as an adverse effect that should be reported to the provider?

Black, tarry stools

A nurse is assessing a client who has hypermagnesemia. Which of the following manifestations should the nurse expect?

Bradycardia

A nurse is providing home care instructions to a client who had a short-arm plaster cast applied for a wrist fracture. Which of the following instructions should the nurse include? A. apply heat B. Wear a sling C. Elevate the wrist above the heart D. Use a soft bristle toothbrush to relieve itching under the cast

C. Elevate the wrist above the heart -instruct the client to elevate the wrist above heart level to reduce swelling and minimize pain.

A nurse in an emergency department is assessing a client who is experiencing mild hypothermia. Which of the following manifestations should the nurse expect? A. Stupor B. Decreased Pulse C. Slurred Speech D. Dysrhythmias

C. Slurred Speech - The nurse should expect a client who is experiencing mild hypothermia to exhibit manifestations such as slurred speech, shivering, decreased coordination, and diuresis.

A nurse is an emergency department is assessing a client who has type 1 diabetes mellitus. Which of the following findings should the nurse identify as an indication that the client has diabetic ketoacidosis? A: Seizure activity B: Nervousness C: Blood glucose 396 mg/dL D: Serum pH 7.52

C.Blood glucose 396 mg/dL -A client who has diabetic ketoacidosis will have a blood glucose level above 300 mg/dL.

A nurse is teaching a client who has asthma how to use a peak flow meter. Which of the following statements should the nurse identify as an indication the client understands the teaching? A: "I will blow out as hard as I can before I use the peak flow meter." B: "I will not take my controller medication if my peak flow meter scores in the yellow zone." C: "I will base my peak flow meter score on the best of three attempts." D: "I will go to the emergency room if my peak flow meter is in the green zone."

C: "I will base my peak flow meter score on the best of three attempts."

A nurse is providing teaching to a client who has diabetes mellitus and a new prescription for extended-release metformin. Which of the following client statements indicates an understanding of the teaching? A: "I will avoid drinking grapefruit juice." B: "I will chew the medication if I can't swallow it whole." C: "I will call the doctor if I have muscle pain in my back." D: "I will take this medication on an empty stomach."

C: "I will call the doctor if I have muscle pain in my back." - Metformin, a biguanide, can cause lactic acidosis, which is a life-threatening complication manifesting as muscle aches, sleepiness, malaise, and hyperventilation. If these manifestations develop, the client should stop taking the medication and notify the provider immediately.

A nurse is providing teaching to a client who has a hearing impairment and has a new prescription for a hearing aid. Which of the following client statements indicates an understanding of the teaching? A: "I should wipe off the hearing aid each day with an alcohol wipe." B: "I will change the battery in the hearing aid when it makes a whistling sound." C: "I will make sure the hearing aid is off before inserting it in my ear." D: "I should start wearing the hearing aid for at least 1 hour at a time."

C: "I will make sure the hearing aid is off before inserting it in my ear."

A nurse is teaching a client who has scabies about a new prescription for lindane lotion. Which of the following client statements indicates an understanding of the treatment for this parasitic infection? A: "I will apply the lotion once a day for 1 week." B: "I will rub in the lotion thoroughly from my face to my toes." C: "I will wash the lotion off 12 hours after I apply it." D: "I should avoid bathing for 6 hours prior to applying the lotion."

C: "I will wash the lotion off 12 hours after I apply it." -The nurse should instruct the client to apply the lotion and leave it in place for 8 to 12 hr and then remove it by washing it off.

A community health nurse is teaching a group of older adult clients about interventions to prevent pneumonia. Which of the following instructions should the nurse include in the teaching? A: "Obtain a pneumococcal vaccination every 2 years." B: "Contact your provider if you have a fever that lasts 18 hours." C: "Wash your hands when you return home from running errands." D: "Avoid exposure to cold air by shopping inside enclosed malls."

C: "Wash your hands when you return home from running errands."

A nurse is teaching a client who has asthma about medications to treat an acute asthma attack. Which of the following medications should the nurse include in the teaching? A: Fluticasone B: Salmeterol C: Albuterol D: Montelukast

C: Albuterol

A nurse is planning care for a client who had surgery for osteomyelitis from a past musculoskeletal trauma to the lower leg. Which of the following interventions should the nurse include in the plan of care? A: Position the affected leg flat when sitting up in bed. B: Instruct the client to perform weight-bearing activities on the affected leg. C: Check for paresthesia of the affected leg. D: Apply heat to the surgical incision area of the affected leg.

C: Check for paresthesia of the affected leg.

A nurse is assessing for manifestations of hyponatremia in a client who has been taking twice the prescribed dose of a diuretic. Which of the following findings should the nurse expect? A: Increased deep tendon reflexes B: Hypoactive bowel sounds C: Decreased level of consciousness D: Bradycardia

C: Decreased level of consciousness -The nurse should expect a client who has hyponatremia to have cerebral edema and increased intracranial pressure as fluid moves into the cells in the brain. This can manifest as confusion, changes in level of consciousness, and seizures.

A nurse is caring for a client who has cellulitis of the lower extremity. Which of the following actions should the nurse take? A: Apply cold packs to the affected area. B: Treat the affected area with propranolol. C: Elevate the affected area 15.24 cm (6 in) above the heart. D: Place a dry heating pad over the affected area. E: Administer cefazolin intermittent IV bolus

C: Elevate the affected area 15.24 cm (6 in) above the heart. E: Administer cefazolin intermittent IV bolus

A nurse is planning care for a client who has renal calculi. WHich of the following interventions should the nurse include to promote elimination of the calculi? A: Maintain bedrest until calculi are expelled. B: Withhold thiazide diuretics. C: Encourage intake of at least 3 L of fluid each day. D: Collect all urine for 24 hr in a collection container

C: Encourage intake of at least 3 L of fluid each day. -Increased fluid intake increases urine production, promotes eliminiation of calculi, and helps prevent recurrence.

A nurse is assessing a client who has Graves' disease. Which of the following findings should the nurse expect? A: Somnolence B: Cold intolerance C: Exophthalmos D: Dry, scaly skin

C: Exophthalmos -The nurse should expect a client who has Graves' disease, an autoimmune form of hyperthyroidism, to experience exophthalmos, which is protrusion of the eyeballs.

A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following manifestations should the nurse expect?A: Otitis media B: Parotitis C: Facial eruption D: Lymphadenopathy

C: Facial eruption - The child has a "slapped face" appearance. The eruption generally disappears after 4 days, but can reappear if the skin is traumatized or irritated by sun, heat, cold, or friction.

A nurse is assessing a client who has been taking antacids frequently for gastrointestinal distress. The assessment findings include drowsiness, muscle weakness, bradycardia, and hypotension. Which of the following electrolyte imbalances should the nurse suspect? A: Hypophosphatemia B: Hypochloremia C: Hypermagnesemia D: Hypernatremia

C: Hypermagnesemia -antacids and laxatives that contain magnesium can cause hypermagnesemia. Manifestations include hypotension, bradycardia, absent deep tendon reflexes, weak skeletal muscle contractions, ECG changes, lethargy, and drowsiness that can progress to coma.

A nurse is teaching a client who has atherosclerosis about self-care. Which of the following instructions should the nurse include in the teaching? A: Consume five to seven servings of red meat per week. B: Limit daily calorie intake from saturated fat to 18%. C: Increase fiber intake to at least 30 g per day. D: Exercise 2 days a week for at least 60 min

C: Increase fiber intake to at least 30 g per day. -Fiber assists in the elimination of lipids and minimizes the development of atherosclerosis.

A nurse on a pediatric unit is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? A: Place the child in a room equipped with a positive-pressure airflow system. B: Place the child in a room equipped with a negative-pressure airflow system. C: Initiate droplet precautions for the child. D: Initiate contact precautions for the child.

C: Initiate droplet precautions for the child.

A nurse is planning care for a client who is postoperative and has developed left lower leg deep-vein thrombosis. Which of the following interventions should the nurse include in the plan of care? A: Initiate complete bed rest .B: Massage the left lower leg three times a day. C: Make sure the client's legs are elevated while in bed. D: Apply cold compresses to the left lower leg every 2 hr.

C: Make sure the client's legs are elevated while in bed. -The nurse should ensure the client elevates her legs in bed and wears antiembolic stockings to help prevent venous insufficiency.

A nurse is teaching a female adult client who is obese about disease management. Which of the following information should the nurse include in the teaching? A: Average body fat for women is 15%. B: Obesity can cause osteoporosis C: Morbid obesity is measured as a BMI over 40. D: Coronary artery disease increases with a waist size of 81.28 cm (32 in).

C: Morbid obesity is measured as a BMI over 40.

A nurse is assessing a client who has social phobia and reports feeling fear and panic when at social gatherings. Which of the following medications should the nurse expect the provider to prescribe? A: Carbamazepine B: Risperidone C: Paroxetine D: Quetiapine

C: Paroxetine -Paroxetine is a selective serotonin reuptake inhibitor that is used to treat social anxiety disorder.

A nurse is reviewing the urinalysis results of a client who has completed a 14-day course of ciprofloxacin to treat pyelonephritis. WHich of the following values should indicate to the nurse that the client has a continuing infection? A: Negative nitrites B: RBCs < 2 C: Positive leukocyte esterase D: Amber-colored urine

C: Positive leukocyte esterase -The nurse should identify that a positive leukocyte esterase test is an indication of the presence of WBCs in the urine and the presence of continued infection.

A nurse is caring for a client who has respiratory depression following opioid administration to control cancer-related pain. The client's ABG results are ph 7.28, PaCO2 49 mm Hg, and HCO3 24 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances?A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis

C: Respiratory acidosis

A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include in the plan? A: Direct the client to perform incentive spirometry every 2 hr. B: Titrate oxygen to maintain the client's oxygen saturation level at 90%. C: Teach the client how to cough up secretions. D: Maintain the client in a low-Fowler's position

C: Teach the client how to cough up secretions. - The nurse should instruct the client how to cough and breathe deeply to expel productive secretions and clear the airway for optimal breathing.

A nurse is assessing a client who is 1 hour postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. For which of the following assessment findings should the nurse notify the provider? A: Urine color is light pink. B: The suprapubic area is soft to palpation. C: The catheter tubing has multiple red clots. D: The bowel sounds are hypoactive

C: The catheter tubing has multiple red clots. -The nurse should identify that the presence of multiple red clots in the catheter tubing or drainage that is ketchup-like are manifestations of postoperative bleeding. The nurse should notify the provider and provide hand irrigation of the bladder per provider prescription.

A nurse is assessing a client who has a potassium level of 2.6 mg/dL and is receiving potassium chloride by continuous IV infusion. Which of the following findings should the nurse identify as an indication that the potassium infusion has brought the client's potassium level back to the expected reference range? A: The client's ECG shows inverted T waves. B: The client's bowel sounds become hyperactive. C: The client's hand grasp becomes stronger. D: The client's standing systolic BP is within 30 mm Hg of her sitting systolic BP.

C: The client's hand grasp becomes stronger. -The nurse should identify that hypokalemia can cause a decrease of skeletal muscle strength. An improvement in the client's hand grasp indicates that the potassium chloride infusion is correcting this electrolyte imbalance.

A nurse is assessing a client who is 1 day postoperative following open ileostomy placement to treat an inflammatory bowel disorder. Which of the following findings is the priority for the nurse to report to the provider? A: The stool is a dark green liquid with a small amount of blood. B: The ileostomy output is 1,000 mL for the past 24 hr. C: The stoma is purple in color. D: The output from the NG tube has decreased over the past 24 hr

C: The stoma is purple in color. - stomas should be pink to bright red in color and shiny. A stoma that is pale bluish, dark red-purplish, or black in color is not receiving adequate blood supply.

A nurse is caring for a toddler who sustained a left lower leg fracture in a motor vehicle crash. The toddler, who has light-pigmented skin, received a cast 24 hours ago. Which of the following assessment findings from the casted leg should the nurse report to the provider?A: The toddler's toes are pink in color. B: The toddler's foot swells when dependent. C: The toddler's toe movement is limited. D: The toddler's capillary refill time is less than 2 seconds.

C: The toddler's toe movement is limited.

A nurse is providing dietary teaching for a client who has GERD. The nurse should instruct the client to avoid which of the following items?

Caffeinated coffee

A nurse is assessing a 6-month-old infant who has gastroenteritis with mild dehydration. Which of the following findings should the nurse expect?

Capillary refill greater than 2 seconds

A nurse is assessing a client who has a new diagnosis of hypothyroidism. Which of the following manifestations should the nurse expect?

Cold intolerance

A nurse is providing teaching about home care to the parent of a child who has pediculosis capitis. Which of the following information should the nurse include?

Comb the child's hair daily with an extra fine-tooth comb

A nurse is assessing a client who is receiving intravenous medications. Which of the following findings should the nurse identify as a manifestation of respiratory acidosis?

Confusion

A nurse on a pediatric unit is preparing an in-service for coworkers about failure to thrive in infants. Which of the following risk factors should the nurse include?

Congenital heart disease

A nurse is caring for a client who has severe hypothermia. Which of the following actions should the nurse take?

Contact a specialized team to place the client on cardiopulmonary bypass

A nurse is assessing a client for manifestations of left-sided heart failure. Which of the following findings should the nurse expect? -Weight gain -Enlarged liver -Distended abdomen -Cool extremities

Cool extremities The nurse should expect to find cool extremities in the client who has left-sided heart failure due to a decreased cardiac output leading to impaired tissue perfusion.

A nurse is reviewing the laboratory results of a client who is receiving gentamicin for the treatment of an infection related to renal calculi. Which of the following findings should the nurse report immediately to the provider?

Creatinine 2.5 mg/dL

A nurse is caring for a client who has a generalized anxiety disorder and is experiencing a mild level of anxiety. Which of the following manifestations should the nurse expect? A. Chest pain B. Hallucinations C. Feels unreal D. Follows directions

D. Follows directions -able to follow directions and focus on the nurse's instructions. Other manifestations the nurse should expect include restlessness, heightened perception, and ability to problem solve.

A nurse is admitting a client who has an acute bacterial wound infection and a temp of 103.6. Which of the following actions should the nurse take? A. Obtain a wound culture 30 min after initiating IV antibiotics B. Place a fan on the lowest setting in the clients room C. Apply a cooling blanket directly on the client skin D. Set the temp of the clients room to 72

D. Set the temp of the clients room to 72 - The nurse should set the temperature of the client's (70° F to 80° F). This promotes a reduction in the client's fever without causing shivering. By combining nonpharmacological interventions with antipyretics, the nurse can reduce the client's fever.

The patient reports severe constipation. The nurse should identify which of the following findings is an indication that the client might have a small bowel obstruction? A. Peripheral edema B. Minimal vomiting C. Intermittent cramping in the lower abdomen D. Visible peristaltic waves in the upper abdomen

D. Visible peristaltic waves in the upper abdomen

A nurse is providing teaching to an adolescent client who has methicillin-resistant Staphylococcus aureus. Which of the following instructions should the nurse provide to prevent the spread of this infection? A: "Expose the infected areas of skin to open air and sunlight as much as possible." B: "Bathe in a tub of warm water using mild soap twice daily." C: "Place soiled dressing bandages in a red biohazard bag for disposal." D: "Do not return to football practice until the infection has healed."

D: "Do not return to football practice until the infection has healed."

A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux about home care. Which of the following statements by the parent indicates an understanding of the teaching? A: "I should feed my infant a larger amount of formula less frequently." B: "I should feed my infant a bottle of formula within 1 hour of bedtime." C: "I should place my infant on his side to sleep." D: "I should add 1 teaspoon of rice cereal to my infant's formula."

D: "I should add 1 teaspoon of rice cereal to my infant's formula." -The parent should add 1 teaspoon to 1 tablespoon of rice cereal in order to thicken the formula. This will decrease the incidence of gastric reflux.

A nurse is providing discharge teaching to an older adult client who had surgery to treat visual impairment due to cataracts. Which of the following client statements indicates an understanding of the teaching? A: "I will keep an eye patch in place for the first 3 days after surgery. "B: "It is okay for me to lift my 2-year-old granddaughter." C: "I will be able run the vacuum cleaner in a day or two." D: "It might take 4 to 6 weeks for my vision to fully improve."

D: "It might take 4 to 6 weeks for my vision to fully improve."

discharge teaching to a client who is postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching? A: "Notify your provider if you notice small pieces of tissue in your urine." B: "Any urinary incontinence will be permanent." C: "Expect to see an increase in the amount of semen produced." D: "Perform Kegel exercises several times throughout the day."

D: "Perform Kegel exercises several times throughout the day."

A nurse in a provider's office is assessing a preschooler who has developed contact dermatitis following exposure to poison ivy. Which of the following statements should the nurse make to the child's parent regarding disease management? A: "Wash your child's exposed clothing in cold water using powder detergent." B: "Keep your child away from other children for 10 days after lesions appear." C: "Scrub your child's affected areas with an antibacterial soap every other day." D: "Place your child in an oatmeal bath using tepid water for 15 minutes."

D: "Place your child in an oatmeal bath using tepid water for 15 minutes." -The nurse should instruct the parent that tepid baths containing oatmeal or mineral oil can decrease itching and evenly disperse the antipruritic solution. The parent should not place the child in a hot bath as this can aggravate the child's condition and increase itching.

nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following information should the nurse include in the teaching? A: "If you miss a dose, you should take two doses the next morning." B: "You should stop taking this medication immediately if you experience depression." C: "You might experience an increased sensitivity to heat while taking this medication." D: "You should contact your provider if your pulse rate drops below 60 per minute."

D: "You should contact your provider if your pulse rate drops below 60 per minute."

A nurse is assessing a 3-month-old infant who has gastroenteritis with severe dehydration. Which of the following findings should the nurse expect? A: Flat anterior fontanel B: Capillary refill 2 seconds C: 5% weight loss D: Absence of tears

D: Absence of tears -The nurse should expect an infant who has severe dehydration to have an absence of tears when crying. Other manifestations include tachycardia, hypotension, intense thirst, and oliguria or anuria.

the nurse is developing an in-service for a group of coworkers about adolescents' reactions to death. Which of the following information should the nurse include when discussing an adolescent's response to death? A: Adolescents cope with death better than children of other ages. B: Adolescents view funeral services as an opportunity for closure. C: Adolescents are more concerned with the past than the present or future. D: Adolescents often alienate themselves from their peers when grieving.

D: Adolescents often alienate themselves from their peers when grieving.

A nurse is caring for a preschooler who has a terminal illness. Which of the following reactions to death should the nurse expect the preschooler to exhibit? A: Fears transmitting their disease to others B: Personifies death as being a type of monster C: Exhibits interest in what happens to the body following death D: Believes death is a temporary type of sleep E: Believes that their own thoughts can cause death

D: Believes death is a temporary type of sleep E: Believes that their own thoughts can cause death

A nurse in an emergency department is assessing a preschooler who has severe dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following findings should the nurse identify as an indication that the treatment is effective? A: Urine output 0.5 mL/kg/hr B: Capillary refill 3 seconds C: Heart rate 148/min D: Brisk skin turgor

D: Brisk skin turgor -The nurse should expect the child to have brisk skin turgor if fluid replacement therapy is effective.

A nurse is assessing an older adult client who is experiencing malnutrition. Which of the following findings should the nurse expect? A: Periorbital edema B: Diaphoretic skin C: Clubbing of fingers D: Brittle hair

D: Brittle hair -The nurse should expect a client who is experiencing malnutrition to have dry, brittle hair, muscle wasting, a depressed mood, and poor wound healing.

A nurse is teaching a client who has type 1 diabetes mellitus about actions to take when having manifestations of hypoglycemia with a glucometer reading between 40 and 60 mg/dL. Which of the following instructions should the nurse include? A: Self-administer 1 mg of glucagon subcutaneously. B: Self-administer 20 units of regular insulin. C: Drink 120 mL (4 oz) of skim milk. D: Drink 120 mL (4 oz) of fruit juice.

D: Drink 120 mL (4 oz) of fruit juice.

A nurse is teaching about herbal supplements with a group of newly licensed nurses. Which of the following herbal supplements should the nurse include in the teaching for treating hyperlipidemia? A: Feverfew B: Gingko C: Valerian D: Garlic

D: Garlic

A nurse is admitting a client who has just been diagnosed with active tuberculosis and has experienced a 5.9 kg (13 lb) weight loss during the past 3 weeks. Which of the following actions should the nurse take first? A: Obtain a sputum sample for mycobacterial culture. B: Administer the first dose of antimycobacterial medications. C: Refer the client to a dietitian to plan a healthy diet. D: Initiate airborne precautions.

D: Initiate airborne precautions. - greatest risk is that the client can transmit tuberculosis to other individuals; therefore, the first action the nurse should take is to initiate airborne precautions for this client.

A nurse is reviewing the laboratory report of a client who is taking exenatide to treat type 2 diabetes mellitus. The nurse should recognize that which of the following laboratory results is an indication of an adverse reaction to the medication? A: HbA1c 6.8% B: Hct 45% C: Creatinine 0.9 mg/dL D: Lipase 185 units/L

D: Lipase 185 units/L -The nurse should recognize that an elevated lipase is an indication of pancreatitis, which can indicate the client is experiencing an adverse effect to exenatide. Physical manifestations of pancreatitis include ongoing, severe abdominal pain and vomiting.

A nurse is planning care for a client who has chemotherapy-induced anemia and is starting epoetin. Which of the following interventions should the nurse include in the plan? A: Shake the medication vial prior to drawing up the medication. B: Withhold epoetin if hemoglobin is less than 9 g/dL. C: Initiate contact isolation. D: Monitor for hypertension.

D: Monitor for hypertension. -blood pressure while receiving epoetin to identify and treat hypertension. Hypertension and cardiovascular events, such as myocardial infarction and stroke, are adverse effects of epoetin.

A nurse is assessing a client who has COPD and is receiving nebulized acetylcysteine. Which of the following findings should the nurse expect if the medication has been effective? A: Cough has been suppressed. B: WBC count is within expected reference range. C: Blood glucose levels are increased .D: Mucus is thin and white in color

D: Mucus is thin and white in color -The client who has COPD can experience manifestations of thick, tenacious secretions. White or clear mucus is an expected finding, which indicates the client is free of respiratory infection. Acetylcysteine is a mucolytic used to thin secretions and enable the client to expectorate them more easily.

A nurse is developing a plan of care for a preschooler who has heart failure. Which of the following interventions should the nurse include in the plan? A: Assess and record the child's blood pressure every 6 to 8 hr. B: Weigh the child once each week using the same scale. C: Place the child in a supine position for a minimum of 4 hr each day. D: Offer small, frequent meals based on the child's endurance level.

D: Offer small, frequent meals based on the child's endurance level.

A nurse is providing discharge teaching for a client who had lithotripsy to break up calculi in the right kidney. Which of the following findings should the nurse instruct the client to report to the provider? A: Bruising over the right flank area B: Blood-tinged urine C: Urine pH 6.0 D: Painful urination

D: Painful urination -client to immediately report flank or bladder pain, chills and fever, or difficulty urinating to the provider. Development of difficulty urinating, including decreased urine output or pain with urination, can mean that the client is developing an infection or can signal reoccurrence of a stone.

A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent reflux. Which of the following information should the nurse include in the teaching? A: Drink tomato juice with the breakfast meal. B: Suck on peppermint when having indigestion. C: Elevate the head of the bed 10 cm (4 in) using wooden blocks. D: Plan to finish eating at least 3 hr before bedtime.

D: Plan to finish eating at least 3 hr before bedtime.

A nurse is caring for a client who is receiving heparin therapy and has an aPTT of 92 seconds. Which of the following medications should the nurse anticipate the provider might prescribe for the client? A: Leucovorin B: Vitamin K C: Deferoxamine D: Protamine

D: Protamine -When there are manifestations of a heparin overdose, the nurse should anticipate that the provider might prescribe protamine to inactivate the heparin. In addition, the nurse should decrease or stop the heparin therapy for a period of time and recheck the aPTT level prior to restarting the heparin. The effects of protamine will last up to 2 hr.

A nurse is teaching about foot care with a group of older adults who have type 1 diabetes mellitus. Which of the following information should the nurse include in the teaching? A: Soak feet daily to soften calluses. B: Apply a heating pad to the feet to improve circulation. C: Choose sandals with open toes to wear in the summer. D: Trim toenails straight across to prevent ingrown toenails.

D: Trim toenails straight across to prevent ingrown toenails.

A nurse is admitting a client who has peptic ulcer disease and an upper gastrointestinal bleed. Which of the following manifestations should the nurse expect? Select all that apply

Dark tarry stools, bright red emesis, increased heart rate

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? -Brown discoloration of the lower extremities -Superficial ulcer on the medial aspect of the ankle -Dependent rubor -Telangiectasias

Dependent rubor The nurse should expect redness to the lower extremities, or dependent rubor, when the client's legs are dangling or in a dependent position.

A nurse is reviewing the medical record of a client who has decreased urinary output. Which of the following findings should the nurse identify as a risk factor for the development of pyelonephritis?

Diabetes mellitus

A nurse is caring for a client who has renal calculi and is taking oxybutynin for pain. Which of the following findings should the nurse identify as an adverse effect of this medication? -Increased salivation -Bradycardia -Tinnitus -Distended bladder

Distended bladder The nurse should identify oxybutynin as having anticholinergic effects that can result in urinary retention. The nurse should monitor the client's intake and output and assess for bladder distention.

A nurse is planning discharge teaching for the parent of a newborn. Which of the following information should the nurse include?

Do not bathe your newborn immediately after she eats

A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make?

Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet

A nurse is developing a plan of care for a client who is 1 hr postoperative following open carpal tunnel release to treat a musculoskeletal injury. Which of the following interventions should the nurse include in the plan?

Elevate the client's arm above the heart

A nurse is caring for a client who has developed cellulitis in a lower extremity. Which of the following actions should the nurse take? -Apply warm dary packs initially then apply cool moist packs to the lower extremity -Elevate the extremity 7.6 to 15.2 cm above heart level -Gently massage the affected extremity for 10-15 min every shift -Apply a topical corticosteroid to any open areas on the affected extremity twice per day

Elevate the extremity 7.6 to 15.2 cm above heart level The nurse should elevate the client's affected extremity 7.6 to 15.2 cm (3 to 6 in) above the heart to promote venous return and decrease edema.

A nurse is assessing for adverse medication reactions with a client who reports taking more than the recommended doses of acetaminophen for the management of chronic pain. Which of the following findings should the nurse identify as an adverse effect of acetaminophen?

Elevated aspartate aminotransferase levels

A nurse is assessing an infant whose guardian reports, "My baby has been crying nonstop, has a fever, and has been pulling at her ear." Which of the following manifestations should the nurse expect for an infant who might have otitis media ? -Enlarged postauricular lymph nodes -Increased flatulence with constipation -Indicates a desire to such more frequently -Slow bounding heart rate

Enlarged postauricular lymph nodes The nurse should expect an infant who has otitis media to have enlarged postauricular and cervical lymph nodes, fever, pain, rhinorrhea, vomiting, and diarrhea. The fever might be as high as 40° C (104° F).

A nurse is caring for a client who has respiratory acidosis due to opioid oversedation. Which of the following actions should the nurse take first?

Ensure a patent airway using a chin-lift maneuver

A nurse is caring for a client who has generalized anxiety disorder. Which of the following medications should the nurse plan to administer?

Escitalopram

A nurse is counseling a client who recently lost her partner in a motor-vehicle crash. Which of the following reactions should the nurse identify as part of the second stage of the grieving process?

Feeling anger toward family members

A nurse is assessing a client who has acute cholecystitis. Which of the following findings should the nurse expect? Select all that apply

Fever, Dyspepsia, Eructation

A nurse is teaching a client who has a new diagnosis of peripheral neuropathy about foot care. Which of the following statements should the nurse include?

File your toenails straight across to prevent ingrown toenails

A nurse is monitoring a client who has metabolic acidosis due to salicylate overdose. For which of the following findings should the nurse monitor? -Flushed, dry skin -Seizures -Hyperreflexia -Positive Trousseau's sign

Flushed, dry skin The nurse should monitor a client who has metabolic acidosis for manifestations of warm, flushed, and dry skin due to vasodilation from an increased respiratory rate and the loss of CO2.

A nurse is assessing a client who has generalized anxiety disorder and is experiencing a moderate level of anxiety. Which of the following manifestations should the nurse expect?

Focuses on the source of anxiety

A nurse is providing teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include?

Give a second injection if the first fails to reverse your child's symptoms

A nurse is assessing a client for manifestations of GERD. Which of the following findings indicates to the nurse that the client might have GERD? -Decreased salivation -Diarrhea -Tonsillitis -Globus

Globus The client who has manifestations of GERD will have globus, which is a feeling of something being in the back of the throat.

A nurse in a community health clinic is reviewing data from the medical records of four clients. Which of the following communicable diseases requires reporting by the nurse? -Gonorrhea -Herpes genitalis -Human papillomavirus -Bacterial vaginosis

Gonorrhea Gonorrhea is an infectious condition listed on the Nationally Notifiable Infectious Conditions Listing. The nurse should report this communicable disease to the Centers for Disease Control and Prevention.

A nurse is reviewing the laboratory results of an adult male client who has hyperlipidemia and is making lifestyle changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has achieved a therapeutic response? -LDL 168 mg/dL -HDL 50 mg/dL -Total cholesterol 268 mg/dL -Triglycerides 250 mg/dL

HDL 50 mg/dL This finding indicates that the client has achieved a therapeutic response from a lifestyle change because the HDL is within the expected reference range of greater than 45 mg/dL for an adult male client.

A nurse is conducting a visual assessment for a client who is at risk for developing glaucoma. Which of the following findings should the nurse identify as a risk factor for this condition?

Heredity

A nurse is participating in a health fair by providing screenings for osteoporosis. Which of the following should the nurse recognize as a risk factor for the disease? -BMI 26 or above -Excessive sun exposure -Frequent weight-bearing exercise -Hip fracture 6 months ago

Hip fracture 6 months ago The nurse should recognize that a client who has a history of hip fracture, especially after the age of 50, is at greater risk for developing regional osteoporosis.

A nurse is preparing to administer medication to a client who has a history of hypertension. The nurse should identify that which of the following is administered for antihypertensive therapy?

Hydrochlorothiazide

A nurse is reviewing the medical record of a client who has age-related macular degeneration (AMD). Which of the following findings should the nurse identify as a risk factor for this visual impairment?

Hypertension

A nurse is caring for a client who is experiencing a hyperglycemic-hyperosmolar state related to complications of diabetes mellitus. Which of the following findings should the nurse expect?

Hypotension

A nurse is assessing a client who has generalized anxiety disorder and has been practicing adaptive use of coping mechanisms. Which of the following responses indicates the client's adaptive use of suppression?

I avoid thinking about problems that worry me until I have time to focus on a solution

A nurse is providing teaching for a client following cataract surgery. Which of the following statements indicates to the nurse that the client understands the teaching?

I should avoid using the vacuum cleaner for several weeks

A nurse is providing teaching for a client who has peripheral neuropathy of the lower extremities. Which of the following client statements indicates an understanding of the teaching?

I should limit wearing the same shoes 2 days in a row

A nurse is providing teaching about home care with a parent of a child who has scabies. Which of the following statements by the parent indicates an understanding of the teaching?

I should wash my child's bed linens and clothing in hot water and detergent

A nurse is providing discharge teaching for a client who has a new diagnosis of COPD. Which of the following client statements indicates an understanding of the teaching?

I will breathe out slowly through pursed lips if I feel short of breath

A nurse is teaching about ezetimibe with a client who has hyperlipidemia. Which of the following client statements indicates an understanding of the teaching? -I should avoid this medication with milk -I will return to have my cholesterol levels checked in 2 weeks -I can expect to lose weight while taking this medication -I understand that muscle tenderness is an expected result of this medication

I will return to have my cholesterol levels checked in 2 weeks

A nurse is providing teaching about home care with an adolescent client who has a skin infection caused by MRSA. Which of the following client statements indicates an understanding of the teaching? -I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach -I will wash my clothes in cold water and detergent -I will throw away my razor after using it three times -I will apply imiquimod cream to the lesions before going to bed each night

I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach The client should soak for at least 5 min in a bathtub filled one-fourth full of water with ½ cup of bleach once or twice per week. This will help prevent reoccurrence of the infection.

A nurse is providing teaching to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) skin infection. Which of the following client statements indicates an understanding of the management of antibiotic resistant infections? -I will keep the infected area open to air to help it heal -I can sleep in the same bed as my partner after I have been taking antibiotics for 24 hours -I should sit on upholstered chairs instead of hardback chairs -I will wash all uninfected skin areas with a fresh washcloth

I will wash all uninfected skin areas with a fresh washcloth The nurse should instruct the client to wash the uninfected skin areas with a fresh washcloth to prevent contamination of the unaffected areas of the skin with the MRSA infection.

A nurse is teaching a client who has COPD about preventing pneumonia. Which of the following client statements indicates an understanding of the teaching?

I will wash my hands whenever I come home from the grocery store

A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching?

I'll wash my feet everyday with soap and lukewarm water

A nurse is assessing a school-age child who has asthma and shortness of breath. Which of the following assessment findings should the nurse identify as the priority?

Inaudible lung sounds

A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of the following manifestations should the nurse expect? -Increased urination -Sweating -Dizziness -Loose stools

Increased urination The nurse should expect the client to exhibit manifestations of hyperglycemia, including increased thirst, nausea, vomiting, increased urination, flushed dry skin, acetone breath odor, and a weak, rapid pulse.

A nurse is admitting an infant who has pertussis. Which of the following actions should the nurse take?

Initiate droplet precautions for the infant

A nurse is planning discharge for a postpartum client. The client tells the nurse she is having subdermal implant placed for contraception at her 6 week follow-up examination and asks about the adverse effects of the implant. Which of the following manifestations should the nurse include? -Irregular bleeding -Fatigue -Shoulder pain -Recurrent urinary tract infections (UTIs)

Irregular bleeding The nurse should inform the client that irregular bleeding is possible when using a subdermal implant as a form of contraception. Other possible adverse effects include amenorrhea, heavy bleeding, headaches, nervousness, nausea, skin changes, and vertigo. With this method, a very small rod is placed on the underside of the upper arm, just underneath the skin. The implant is hardly noticeable and compared to oral contraceptives, the failure rate is less than 1%. One of the major advantages with this method is that fertility rapidly returns after its removal.

A nurse is assessing a client for manifestations of right-sided heart failure. Which of the following findings should the nurse expect? -Jugular vein distention -Fatigue -Angina -Hacking cough

Jugular vein distention The nurse should expect to find jugular vein distention (JVD) in the client who has right-sided heart failure due to right ventricular failure and pressure building in the venous system.

A nurse is providing teaching to a client about preventing hearing loss from trauma. Which of the following instructions should the nurse include in the teaching? -Keep your mouth open when sneezing -Block one nostril when blowing your nose -Use an ear wick candle to remove excess cerumen from the canal -Lubricate cotton-tipped applicators with mineral oil to clean the ear canal

Keep your mouth open when sneezing The nurse should instruct the client to keep the mouth open while sneezing to reduce the pressure in the middle ear. Sudden pressure changes can damage the ossicles and perforate the ear drum.

A nurse is reviewing a client's home medication list during admission to a long-term care facility. The nurse should identify that the client takes which of the following medications to manage osteoarthritis? Select all that apply

Lidocaine 5% patches, Celecoxib, Cyclobenzaprine, Glucosamine

A nurse is providing teaching to a client who has calcium oxalate renal calculi. Which of the following statements should the nurse include in the teaching?

Limit the amount of spinach in your diet

A nurse is teaching a group of newly licensed nurses about risk factors for peptic ulcers. Which of the following risk factors should the nurse include in the teaching?

Long-term use of NSAIDs

A nurse is reviewing the medical record of a client who has AIDS and is experiencing anorexia. Which of the following medications should the nurse expect the provider to prescribe to reduce the client's risk of failure to thrive?

Megestrol

A nurse is planning discharge teaching for the guardian of a child who had a cardiac catheterization. Which of the following instructions should the nurse include? -Monitor the site daily for drainage -Leave the pressure dressing on the 48 hr -Administer aspirin if the child reports pain -Resume tub baths in 24hr

Monitor the site daily for drainage The nurse should instruct the guardian to monitor the site daily for manifestations of infection, such as drainage, redness, and swelling. The guardian should report these findings to the provider.

A nurse is assessing a client who has an external fixator to the right lower arm following musculoskeletal trauma. Which of the following findings should indicate to the nurse that the client has developed compartment syndrome? -Serous drainage is present on the pin site dressings -Flushing of the skin on the right arm -Bounding pulse palpated in the radial artery -Numbness to the fingers on the right arm

Numbness to the fingers on the right arm The nurse should identify a decrease in sensation, such as numbness and tingling of the fingers, as one of the first indications that the client might be developing compartment syndrome of the right lower arm. Compartment syndrome is the result of edema and ischemia, a complication following musculoskeletal injury. Other manifestations include increased pain, paralysis, pallor, and decreased or absent pulses.

A nurse is caring for a client who has pneumonia. Which of the following actions is the priority for the nurse to take? -Monitor intake and output -Provide teaching about antibiotic therapy -Administer the influenza vaccine -Observe the client perform incentive spirometry

Observe the client perform incentive spirometry When using the airway, breathing, and circulation framework, the priority action the nurse should take is to observe the client perform incentive spirometry. Incentive spirometry improves gas exchange and oxygenation and stimulates coughing, which assists in clearing secretions.

A nurse is assessing a client for manifestations of heat stroke. Which of the following findings should the nurse expect?

Oliguria

A nurse is assessing a client who has renal calculi. For which of the following findings should the nurse notify the provider immediately? -Flank pain with radiation toward the scrotum -150 mL emesis -Oliguria with bladder distention -Blood pressure 160/90 mmHg

Oliguria with bladder distention The greatest risk to this client is injury due to bladder obstruction as indicated by decreased urinary output in the presence of bladder distention. The calculi can create an obstruction of the bladder neck or urethra. The nurse should identify this as a medical emergency and notify the provider immediately.

A nurse is assessing an 18-month-old toddler who has gastroenteritis with dehydration. The toddler is able to consume 3 mL of oral rehydration solution every 5 min but still has emesis and diarrhea. Which of the following medications should the nurse anticipate administering to the toddler?

Ondansetron

A nurse is caring for a client who has right-sided hemiparesis following a stroke. Which of the following images is an indication that the nurse is correctly assisting the client to ambulate?

One hand on gait belt walking behind the patient on affected side (right side)

A nurse is teaching a client who has hypokalemia about nutrition management. Which of the following fruits should the nurse recommend as the best source of potassium?

One small orange

A nurse is assessing a client who is experiencing diarrhea and vomiting and has a sodium level of 124 mEq/L. Which of the following manifestations should the nurse expect? -Orthostatic hypotension -Hoarse voice -Neck vein distention -Muscle twitching

Orthostatic hypotension The nurse should monitor the client who has a sodium level of 124 mEq/L for orthostatic hypotension. The expected reference range for sodium is 136 to 145 mEq/L. Other manifestations of hyponatremia include decreased deep tendon reflexes, headache, confusion, and lethargy.

A nurse is assessing a client who has musculoskeletal trauma following a motor-vehicle crash 2 days ago. Which of the following findings should the nurse report to the provider?

Pain report

A nurse is caring for a client who is experiencing an asthma attack. Which of the following procedures should the nurse use to assess the client's respiratory status? -Peak expiratory flow meter testing -Spirometry monitoring -Pulmonary function testing -Chest x-ray

Peak expiratory flow meter testing The peak expiratory flow meter provides a means of evaluating the maximum flow of air the client expels during forceful exhalation. It provides information on how well asthma is being controlled as a part of daily monitoring and can be used when a client is having an asthma attack. The flow meter testing helps to gauge the peak-expiratory zone the client is experiencing and determines if the client should use immediate-acting bronchial dilator inhalers or seek emergency help.

A nurse is providing teaching about exercise to a client who has osteoarthritis. Which of the following information should the nurse include?

Perform exercise even on days when joints are painful

A nurse is assessing a client in the triage room of an emergency department. Based on the client findings, which of the following actions should the nurse take?

Place a surgical mask on the client

A nurse is teaching a group of newly licensed nurses about hypothermia and the care of a client who has frostbite to the fingers and toes from cold exposure. Which of the following information should the nurse include in the teaching about frostbite?

Place the affected areas of frostbite in a warm water bath

A nurse in an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take? -restrict oral intake to clear fluids -place a heating pad on the client's abdomen -place the client in semi-Fowler's position -Administer an enema

Place the client in semi-Fowler's position The nurse should place the client in semi-Fowler's position to contain abdominal drainage in the lower abdomen and prevent it from seeping into the peritoneum.

A nurse is reviewing the laboratory results of an adult client who has metabolic alkalosis. Which of the following findings should the nurse expect?

Potassium 3 mEq/L

A nurse is caring for a client who has deep vein thrombosis and is receiving heparin via continuous IV infusion. The client has a positive fecal occult blood test and abdominal tenderness upon palpation. Which of the following prescription should the nurse expect the provider to prescribe?

Protamine sulfate

A nurse is reviewing a client's medical record prior to a laparoscopic appendectomy. Which of the following findings should the nurse report to the provider?

Report of urinating small amounts twice daily

A nurse in an emergency department is reviewing the laboratory report of a client who has hyperventilation. The client's ABG results are pH 7.50, PaCO2 29 mmHg, and HCO3 25 mEq/L. The nurse should interpret that these values are an indication of which of the following acid-base imbalances?

Respiratory alkalosis

A nurse is assessing a client who has a partial obstruction of the large bowel. Which of the following manifestations should the nurse expect?

Ribbon-like stools

A nurse is performing a focused assessment on a client who has cholelithiasis and reports pain. Which of the following areas should the nurse assess?

Right upper quadrant The nurse should assess the gallbladder for the presence of pain or discomfort as a result of biliary colic, which is caused by a gallbladder stone obstructing the bile duct. The pain can radiate from the right upper quadrant of the client's abdomen to the client's right shoulder.

A nurse in a provider's office is reviewing the medical record of a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider?

Sputum culture shows gram positive bacteria

A nurse is caring for a client who has possible appendicitis. Which of the following actions should the nurse take?

Start IV fluid replacement

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Stay with the client until manifestations subside

A nurse is assessing a client who has deep-vein thrombosis (DVT) in the right lower extremity. Which of the following findings on the affected extremity should the nurse expect?

Swelling

A nurse is reviewing the laboratory results of a client who is scheduled for surgery and notes a potassium level of 6 mEq/L. Which of the following ECG findings should the nurse expect?

Tall T-waves

A nurse is assessing a client whose parents recently died. The nurse should identify that which of the following findings places the client at risk for maladaptive grieving?

The client lost his house in a house fire 1 month ago

A nurse is planning care for a client following collection of admission data. Which of the following findings should the nurse identify as the priority client need?

The client reports coughing and a change of voice whenever he eats

A nurse is assessing a client who has hyperthyroidism and has been taking methimazole for 6 months. Which of the following findings indicates a therapeutic response to the medication -The client's skin is warm and moist -The client reports sleeping longer during the night -The client is experiencing increased bowel movements -The client's weight is 1.4 kg (3.1 lb) less than baseline

The client reports sleeping longer during the night The nurse should recognize that insomnia is a manifestation of hyperthyroidism. The client's ability to sleep longer during the night indicates a therapeutic response to the medication.

A nurse is teaching about clonazepam with a young adult female client who has generalized anxiety disorder. Which of the following statements should the nurse include in the teaching?

This medication could cause you to have thoughts of self-harm

A nurse is assessing a client who has acute pyelonephritis. Which of the following findings should the nurse expect?

Urinary burning

A nurse is planning teaching for an adolescent who has exercise-induced asthma and has new prescriptions for cromolyn and albuterol inhalers. Which of the following instructions should the nurse plan to include in the teaching?

Use albuterol prior to planned exercise

A nurse is assessing a client who has developed Clostridium difficile as an adverse effect to ciprofloxacin. Which of the following medications should the nurse expect the provider to prescribe to treat the C. difficile?

Vancomycin

A nurse is reviewing the laboratory results of a client who is taking sulfasalazine to treat ulcerative colitis. Which of the following laboratory findings should the nurse identify as an adverse effect of sulfasalazine? -Total bilirubin 0.8 mg/dL -WBC count 4,000/mm^3 -Platelets 190,000/mm^3 -Creatinine 1 mg/dL

WBC count 4,000/mm^3 Agranulocytosis, or a very low WBC count, is an adverse effect of sulfasalazine. This condition results in a decreased WBC count. The nurse should identify that a WBC count of 4,000/mm3 is less than the expected reference range of 5,000 to 10,000/mm3, indicating an adverse effect of the medication.

A hospice nurse is visiting with a client following the death of her partner 1 month ago. The client is tearful and states she does not see how she can ever be happy again. Which of the following responses should the nurse make?

What are some of the best times with your partner that you remember?

A nurse is providing dietary teaching to a client who is at 13 weeks gestation and has hyperemesis gravidarum. Which of the following statements should the nurse make?

drink fluids between, rather than with, meals

A nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the following manifestations should the nurse expect?

nasal flaring

A nurse is providing teaching about home care to the parent of an adolescent who has infectious mononucleosis. Which of the following manifestations should the nurse intruct the parent to report to the provider?

onset of abdominal pain

A nurse is providing teaching to a client who has osteoporosis. Which of the following information should the nurse include in the teaching?

perform exercises to strengthen the abdominal core

A home health nurse is assessing a client who has COPD. The client has a respiratory rate of 22/min and reports shortness of breath. Which of the following actions should the nurse take first?

place the client in high-Fowler's position