RN Hurst study quiz

A client diagnosed with human immunodeficiency virus (HIV) is to be sent home today. The nurse has initiated discharge instructions on the proper handling of blood and body fluid at home. The nurse knows the teaching is successful when the client makes what statement?

"I should clean area with a 10% mixture of bleach and water."

Which statement by the nurse would be the correct response to a client who is postmenopausal with a uterus when the client asks about temporary hormonal therapy for hot flashes?

"hormonal therapy with a combination of low doses of estrogen and progestin may be prescribed." - only women without a uterus are prescribed estrogen without progestin (unopposed estrogen) because there is no longer a risk of estrogen-induced hyperplasia of the uterine lining

A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety?

Restrict any visitors with visible illnesses. Methylprednisolone suppresses the immune system, making the client even more at risk of infection.

What signs and symptoms would a nurse assess for in a client who is receiving hospice care and is close to death? Select all that apply

1. Cool extremities 2. Mottling 3. Cheyne-Stokes respirations 4. Loss of appetite

What potential contributing factor for stress urinary incontinence should the nurse assess for in an elderly female client? Select all that apply.

1. Lack of estrogen 2. Rising abdominal pressure 3. Multiparous vaginal births

A 35 year old client, concerned about weight, asks a clinic nurse, "What is my BMI?" The client weighs 135 pounds and is 5 feet 2 inches tall. Determine the client's BMI to the nearest tenth?

24.7 Formula: BMI = (703 x weight in pounds) / (height in inches)2 (703 x 135) / (62)2 (94,905) / (3844) 24.689 24.7

The nurse sis preparing to speak to a group of clients at the community center about influenza. Which risk factors for influenza complications would be included in the session? Select all that apply.

1. Age over 65 years 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home. - the very young, the very old, and people with chronic diseases are more likely to have complications from the flu.

A client diagnosed with gout has received instruction on maintaining a low-purine diet. Which statements, if made by the client, would indicate to the nurse that teaching was successful? Select all that apply.

1. "I will eliminate foods from my diet that contain 150 mg or more of purine per serving." 3. "Losing weight can help reduce the uric acid levels in my blood." 5. "Vegetable that should be limited to 2 times/week include cauliflower, spinach, and mushrooms." 6. "Increasing fluid intake to 8-10 cups/day will help to eliminate purines through my urine."

A nurse has completed education on safe sexual practices to a group of college students. Which comments by the students would indicate that education has been successful? Select all that apply.

1. "The best way to prevent HIV is to abstain from sex." 4. "Drinking too much alcohol can increase the risk exposure to sexually transmitted disease (STDs)." 5. "If my partner will not use a condom, I will."

Which assessment finding on a client four hours post right femoral percutaneous transluminal coronary angioplasty (PTCA) would require immediate intervention by the nurse? Select all that apply

1. Client reports chest discomfort 2. Legs elevated 15 degrees 4. client reports slight tingling to right foot 5. Left pedal pulse 2+/4+, Right pedal pulse 1+/4+

When teaching a client about lactose intolerance, what should the nurse include? Select all that apply.

1. Common symptoms of lactose intolerance include abdominal bloating, diarrhea, and gas. 3. Calcium rich foods should be consumed 4. the client can drink lactose-free milk. 5. Vitamin D foods should be increased in the diet.

The nurse is discharging a client post right radial percutaneous transluminal coronary angioplasty (PTCA) with stent insertion. Which instructions should the nurse give the client to reduce the risk of complications? Select all that apply

3. Drink at least 8 glasses of water a day. 4. Wear loose fitting sleeves 6. Take short walks around your house.

A nurse is planning to teach a group of adult males in their 40's about health care promotion recommendations. Which recommendations should the nurse include? Select all that apply

3. Limit alcohol intake to no more than two drinks per day 5. Get at least 30 minutes of moderate physical exercise on most days of the week.

A client tells a clinic nurse of plans to travel to Europe by plane. What tips should the nurse provide the client regarding prevention of clot formation? Select all that apply.

3. Wear compression stockings while traveling 4. Frequently move legs while sitting 5. avoid coffee while traveling

The pathology report on a client diagnosed with urolithiasis reveals calcium oxalate stones. Which food selections by the client would indicate to the nurse that the client understands the prescribed low oxalate diet?

5. Bananas 6. Raisins

The nurse is providing care to a client who had an endoscopic retrograde cholangiopancreatogram (ERCP) two hours ago. Which finding would indicate a possible complication?

Abdominal pain rated 8/10

An unresponsive client with a respiratory rate of 14/min arrives at the emergency department after attempting suicide in a running car with the garage door closed. What action should the nurse perform FIRST?

Administer 100% O2 per nonrebreather mask

Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse's first action?

Administer 100% oxygen per mask.

A client has returned to the unit following an upper gastrointestinal series (Upper GI). What is the nurse's priority action?

Administer 30 mLs milk of magnesia orally. An Upper GI involves the ingestion of a barium based contrast under fluoroscopy to view the esophagus, stomach, and small intestine. It is vital that the client to pass all the barium before a blockage occurs.

Which assessment finding identified in a client diagnosed with Guillain-Barre Syndrome would indicate that the nurse needs to notify the primary healthcare provider?

Breathlessness while talking. - indicates respiratory fatigue, prep for intubation, mechanical ventilation for vital lung capacity under 800 mL; Imminent signs of respiratory failure include a heart rate greater than 120 bpm, or less than 70 bpm; imminent signs of respiratory failure = resp greater than 30 bpm

Following surgery, a client has an indwelling urinary catheter attached to a collection bag. The nurse empties the collection bag at 0900. At the change of shift at 1500, the collection bag contains 100 mL of urine. The system has no obstructions to urinary flow. What would be the nurse's most appropriate initial response?

Check circulation and take the vital signs of the client. - look for low BP and increased HR as signs of hypovolemic shock

A client has been admitted with a diagnosis of portosystemic encephalopathy secondary to Laennec's cirrhosis. The primary healthcare provider writes prescriptions based on the lab values. The nurse would monitor the effectiveness of medications by observing for what specific neurologic changes in the client? Exhibit: Lab results: Sodium - 129; K - 3.0; Albumin - 2.0; ammonia - 80; bilirubin - 2.0; BUN - 32; Creatinine - 2.0; BP - 100/60; pulse - 110; resp - 28 Exhibit: Medication: furosemide; lactulose; K-Dur; Albumin 25%

Frequent diarrhea with orientation x three Neurologic deterioration in clients with cirrhosis is secondary to increased ammonia levels in the body and brain, resulting in development of encephalopathy. Frequent diarrhea, secondary to the use of lactulose, helps rid the body of ammonia, allowing the client's orientation to improve to normal.

Which menu selection by the client diagnosed with cholelithiasis indicates to the nurse that teaching of proper diet was understood?

Grilled pork chops in peach sauce, baked sweet potato, sherbet. In cholelithiasis, the bile becomes super saturated with cholesterol. This leads to precipitation of cholesterol which presents as gall stones. A client with cholelithiasis should avoid foods high in fat. Foods high in fat include any fried foods, cheeses, milk, custard, cream, ice cream, pies, cakes, red meats, baked beans.

The nurse is caring for a client who is scheduled to receive furosemide 40 mg IVP twice daily, as well as 20 meq (20 mmol/l) of potassium chloride twice daily. The client's lab work reveals that the potassium level is 2.4 mEq/L (2.4 mmol/L) this morning. How should the nurse proceed?

Notify the primary healthcare provider of the potassium level immediately.

A middle-aged client has a strong positive family history of type 2 diabetes mellitus. What should the nurse teach the client regarding the best method to prevent or delay the development of this disease?

Obtain a normal body weight and exercise regularly.